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http://www.archive.org/details/anatomicalatlasoOOscha 


ANATOMICAL  ATLAS 


OBSTETRICS 

WITH   SPECIAL   REFERENCE  TO 

DIAGNOSIS  AND   TREATMENT 

BY 

DR.   OSKAR  SCHAEFFER 

Privatdocent  in  Obstetrics  and  Gynecology  ij:i  the  University  of  Heidelberg 


AUTHORIZED  TRANSLATION   FROM  THE  SECOND  REVISED 
GERMAN    EDITION 


EDITED    BY 


J.   CLIFTON   EDGAR,  A.M.,  M.D. 

Professor  of  Obstetrics  and  Clinical  Midwifery-  in  the  Cornell  University 

Medical  College  ;  Attending  Physician  to  the  Mothers'  and 

Babies'  Hospital  and  the  New  York  Maternity 


With  122  Figures  on  56  Lithographic  Plates,  and  38  other  Dlustrations 
PHILADELPHIA   AND   LONDON 

Vv^.  B.  SAUNDERS   &    COMPANY 
1 901 


Copyright.  1901,  by  W.  B.  SAUNDERS   &    COMPANY. 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTYPED  BY  PRESS  OF 

WESTCOTT  &  THOMSON,  PHILADA.  W.   B.   SAUNDERS  &  COMPANY, 


EDITOR'S  PREFACE. 


In  the  oriorinal,  Dr.  Sehaeffer's  Atlases  were  most  sue- 
cessfal,  and  we  see  no  reason  why  they  should  not  be 
equally  popular  in  the  English  language. 

Volume  I.  many  of  us  will  remember  as  appearing  in 
a  much  smaller  book  in  the  early  nineties  ;  but  this  has 
now  been  much  enlarged  and  brought  up  to  date^  with 
111  pages  of  text  and  over  150  illustrations. 

Volume  II.  contains  314  pages  and  160  valuable  illus- 
trations. Here  we  are  indebted  to  the  author  for  a  book 
which,  although  he  terms  it  an  ''Anatomical  Atlas  of 
Obstetric  Diagnosis  and  Treatment/'  still,  by  reason  of 
its  profusion  of  illustrations  and  diagrams,  is  in  the  main 
a  text-book  of  great  didactic  value. 

The  present  volume  treats  particularly  of  the  obstetric 
operations,  and  will  be  found  of  special  value  for  the 
student  as  a  book  of  reference  to  be  used  in  conjunction 
with  the  larger  treatises  on  obstetrics. 

As  in  Volume  I.,  no  alterations  or  additions  have  been 
made  in  the  text,  with  the  exception  that  the  English 
equivalents  have  been  added  to  all  French  weights  and 
measures. 

J.  CLIFTON  EDGAR. 
50  East  34th  Steeet,  Xew  Yoek, 
January,  1901. 


PREFACE  TO  THE  SECOND  EDITION. 

The  appearance  of  the  second  edition  of  this  work  has 
been  mnch  delayed,  because  both  the  publisher  and  the 
author  were  well  aware  that  this  atlas,  which  was  the 
first  of  the  series  to  appear  with  colored  illustrations,  has 
been  outstripped  by  the  later  issues,  both  as  regards  im- 
provements in  the  technique  and  the  utilization  of  new 
clinical  material.  Meanwhile,  the  atlases  have  gained  a 
place  for  themselves  as  practical  manuals, -and  for  these 
reasons  it  became  necessary  to  subject  both  the  illustra- 
trations  and  the  text  to  a  complete  revision.  Most  of 
the  colored  plates  are  new,  and  have  been  executed  under 
my  direction  by  the  practised  hand  of  Mr.  Schmitson. 
The  sources  from  which  the  new  material  was  derived 
were  the  Heidelberger  Frauenklinik  and  Poliklinik,  the 
Pathological  Institute,  and  the  author's  own  practice. 
I  am  greatly  indebted  to  the  directors  of  those  institu- 
tions, Drs.  Arnold  and  Kehrer,  and  to  their  assistants, 
especially  Professor  Ernst. 

In  regard  to  the  material  from  the  Miinchener  Frauen- 
klinik which  was  included  in  the  first  edition,  I  refer  to 
the  preface  to  that  edition,  and  renew  the  expression  of 
my  grateful  appreciation  of  the  ready  kindness  with  which 
my  former  respected  chief  and  master.  Dr.  von  Winckel, 
not  only  placed  that  clinical  material  at  my  disposition, 
but  assisted  me,  besides,  with  his  inestimable  suggestions, 


PREFACE   TO   THE  SECOND   EDITION. 

which  are  still  found  in  the  corresponding  passages  in 
the  text  and  in  the  illustrations. 

In  this  revision  1  have  been  guided  chietly  by  the 
demands  of  the  practical,  clinical  side  of  obstetrics,  and 
it  is  for  this  reason  that  all  scientitic  explanations  and 
anatomic,  histologic,  and  pathologic  data  are  printed  in  a 
different  type  from  that  of  the  ordinary  text.  In  this 
way  I  have  fully  preserved  the  peculiar  character  of  an 
atlas  accompanied  by  a  complete  abstract. 

Every  chapter  has  been  carefully  revised  and  the  liter- 
ature utilized.  The  advances  made  in  the  last  few  years 
have  been  considerable.  Many  questions  have  been 
brought  nearer  a  final  solution,  many  others  have  become 
more  complicated,  while  new  ones  have  made  their  ap- 
pearance. Hence  it  was  often  necessary  either  simply  to 
cite  all  the  reported  findings,  or  in  other  cases  to  add  to 
them  a  personal  interpretation.  Chapters  of  this  kind 
are  those  on  the  youngest  ova,  on  the  chorionic  epithe- 
lium and  syncytium,  on  the  epitheliomata  of  the  chorion 
and  deciduomata,  the  nature  of  the  ^'  lower  uterine  seg- 
ment "  and  the  "  contraction-ring,"  the  treatment  of 
ectopic  gestation,  hystereurysis  and  kolpeurysis,  of  reflex 
neuroses  and  anomalies  of  innervation,  etc.  In  recogni- 
tion of  the  general  tendency  to  consider  the  body  as  a 
complete  entity,  I  have  thought  it  advisable  to  add  a 
chapter  on  the  mutual  influences  which  the  individual 
organs  exert  on  one  another,  both  from  a  physiologic  and 
a  pathologic  point  of  view,  and  I  have  therefore  at- 
tempted to  build  up  a  practical  system  on  the  basis  of 
my  own  experience  and  of  the  literature  bearing  on  the 
subject.  An  effort  has  been  made  to  discuss  the  symp- 
tomatology with  the   greatest    fulness    compatible    with 


PREFACE  TO   THE  SECOND  EDITION. 

brevity,  instead    of   dismissing  the  subject  with  a  few 

stereotyped  phrases  which  are  of  no  use  in  the  individual 

case.     In  like  manner,  the  indications  for  treatment  have 

been  made  more  complete  and   at  the  same  time  more 

definite. 

Wherever  it  was  possible,  tables  and  schemes  have  been 

added  so  as  to  afford  a  general  view  of  the  subject  under 

discussion.     In  conclusion,  I  must  not  omit  to  state  that 

without  the  self-sacrificing  cooperation  of  the  publisher 

and  the   intelligence  of  Mr.  A.  Schmitson,  such  a  large 

and  complete  collection  of  original  drawings  would  not 

have  been  possible.     I  wish  to  express  to  these  gentlemen 

my  heartfelt  thanks. 

OSKAR   SCHAEFFEE. 


CONTENTS. 


PART    I 

Physiology  and  Dietetics  of  Pregnancy,  Labor, 
and  the  Puerperium. 

CHAPTER  PAGE 

I.  Physiology  and  Diagnosis  of  Pregnancy 11 

1.  Development  of  the  Ovum.     Changes  Observed  in  the 

Organs  of  Gestation  during  Pregnancy 15 

Ovuhition  and  Menstruation 17 

Fertilization  and  Propulsion  of  the  Fertilized  Ovum 

along  the  Oviduct 19 

Development  of  the  Embryo  and  Fetal  Membranes  .  21 
Diagnosis  and  Anatomical  Features  of  Each  Month 

of  Gestation 30 

2.  Examination.     Diagnosis  of  Pregnancy 35 

II.   Anatomy,    Development,    and  Examination   of    the 

Pelvis 49 

3.  Diagnosis  of  the  Normal  Female  Pelvis 49 

4.  Shape  and  Inclination  of  the  Adult  Female  Pelvis  and 

its  Development 56 

Variations  in  the  Pelvic  Inclination  and  their  Practi- 
cal Value 60 

III.  Normal  Labor 62 

5.  The   Uterine  Muscle  and  its  Functions  during  Preg- 

nancy and  Labor 62 

Labor-pains  and  their  Effect  on  the  Fetus 67 

6.  The  First  or  Dilatation  Stage  of  Labor.     Behavior  of 

the   Lower   L^terine   Segment  and  of  the  Cervix 
during  this  Period ...    75 

7.  The  Second  Stage  (Stage  of  Expulsion)  and  the  Resist- 

ance offered  by  the  Pelvic  Planes  and  the  Floor  of 

the  Pelvis 85 

3 


4  CONTENTS. 

CHAPTER  PAGE 

IV.  The  Puerperium  and  the  Treatment  of  the  New- 
born Infant 96 

8.  Physiology  of  the  Puerperium 96 

9.  Physiology  and  Feeding  of  the  New-horn  Infant  .    .    .108 

10.  Hygiene  and  Management  of  Pregnancy 123 

11.  Symptomatology  and  Management  of  the  Puerperium  .  125 


PART   II. 

Pathology  and  Treatment  of  Pregnancy,  Labor, 
and  the  Puerperium. 

V.  The  Pathology  of  Pregnancy,  including   Abor- 
tion AND  Premature  Labor 134 

12.  Anomalies  which  Lead  to  Abortion 134 

Diagnosis  and  Treatment  of  Abortion    ......  134 

Suhchorionic  Hemorrhages 138 

Hydrorrhoea  Uteri  Gravidi 144 

Decidua  Polyposa 145 

Hydatid  Moles 145 

Polyhydramnion      147 

Inflammation  of  the  Placenta 149 

13.  Eclampsia  Gravidarum 152 

14.  The   Eelations   between  Pregnancy  and   Diseases   of 

other  Organs 156 

15.  Disturbances  during  Pregnancy  due  to  Anomalies  in 

the  Shape  and  Position  of  the  Genital  Organs, 

especially  the  Uterus       168 

16.  Tumors    .    .    .    .• 1'^'" 

17.  Ectopic  Gestation.     Placenta  Prapvia      191 

Ectopic  Gestation •    •    •  ^^^ 

Placenta  Praevia •  199 


CONTENTS.  5 

CHAPTER  PAGE 

VI.  Deformities  of  the  Pelvis  and  their  Influence 

ON  Pregnancy  and  Labor 204 

18.  General  Kemarks  on  the  Diagnosis  and  Treatment 

of  Deformed  Pelves 204 

19.  Anatomical   and   Obstetrical    Peculiarities   of  De- 

formed Pelves 209 

Classification  and  Description  of  Deformed  Pelves  212 

Generally  Contracted  Pelves       212 

Anteroposteriorly  Contracted  Pelves     ....  215 

Collapsed  Pelves"^ 222 

Funnel-shaped  Pelves       22-3 

Obliquely  Contracted  Pelves 230 

Transversely  Contracted  Pelves 236 

Anomalies  of  the  Pelvis  due  to  Congenital  or 

Earl}^  Acquired  Defects 237 

Spondylolisthetic  Pelves 239 

Assimilation-pelves    with    so-called    ' '  Inter- 
calated ' '  Vertebra 241 

Anomalies  of  the  Pelvis  due  to  Bone-tumors 

and  Exostoses  the  Eesult  of  Fractures  .    .    .  242 

Generally  Enlarged  Pelves 243 

VII.  Pathology  of  Labor 243 

20.  Lacerations  of  the  Genitalia  during  Labor  ....  243 

21.  Dystocia   due   to   Anomalies   in  the  Position  and 

Form  of  the  Genital  Organs,  including  Tumors  254 

22.  Dystocia  due  to  Anomalies  in  the  Ovum  or  Fetus  .  262 

23.  Anomalies  in   Labor-pains.     Interdependence  be- 

tween Labor  and  Diseases  of  other  than  the 

Sexual  Organs 268 

General  Remarks  on  Diagnosis  and  Indications 

for  Operation  in  Dystocia 268 

Anomalies  in  the  Labor-pains 270 

Interdependence  between  Labor  and  Diseases  of 

other  Organs 274 

VIII.  General   Remarks  on  Exploration  for  Purposes 

OF  Diagnosis  and  Treatment 278 

24.  Preparation  of  the  Patient  for  Examination  and 

Instrumental  Delivery 278 

26.   The  Instrumentarium 281 


6  .        CONTENTS. 

CHAPTER  PAGE 

IX.  Pathology  of  the  Puerperium 283 

26.  Puerperal  Fever 283 

Treatment  of  Acute  Pelveoperitonitis 292 

Treatment  of  General  Septicemia  and  Sapremia  293 

27.  Interdependence  between  the  Puerperal  Processes 

and  other  Diseases 296 

28.  Diseases  of  the  Mammary  Glands  during  the  Puer- 

perium        299 

Prescriptions  Commonly  Used  in  Obstetrical  Practice  .  802 

Index 307 


ILLUSTRATIONS. 


Plate. 

FiGVEE 

1 

1 

2 

3 

2 

4 

5 

6 

7 

3 

8 

4 

9 

10 

11 

5 

12 

13 

6 

U 

15 

16 

7 

17 

8 

18 

9 

19 

10 

20 

11 

23 

12 

24 

13 

25 

14 

26 

15 

27 

16 

28 

17 

29 

30 

18 

31 

19 

32 

33 

Ovary  with  Ampulla  of  Tube. 

Ovary  with  Corpus  Luteum. 

Longitudinal  Section  of  an  Ovary. 

Transver.?e  Section  of  Ovary  from  a  Four-months"  Fetus. 

Longitudinal  Section  thn jugh  the  Ovary  of  a  Xew-born 
Infant. 

Cross-sections  of  an  Oviduct. 

Cross-section  through  the  Isthmus  of  a  G-rarida. 

Embryo  from  an  Abortion  at  the  End  of  the  Second 
)  Month. 

'  Chorion  and  Amniotic  Sac  with  Ovum. 

Decidua  Vera. 

Spurioas  Fetal  Hemains. 

Complete  Ovum  in  the  Second  Month. 

Ovum  of  the  Third  Month. 

Transverse  Section  of  the  Vterus  fntm   a  Six-months' 
Fetus. 
j  Cells  from  Decidua. 

Chorionic  Villus  with  Fetal  Blood-vessels. 

Eare  Vertical  Position  of  the  Gravid  L'terus  in  the  Third 
Month,  following  a  Retroversion . 

Retroverted  Uterus  in  the  Second  Month  of  Gestation. 
]  Gravid  Litems  in  the  Fourth  Month  in  a  Primigravida. 

Gravid  L'terus  in  the  Sixth  Month  in  a  Primigravida. 

Lateral  Placenta  Pra-via.  Sixth  Month. 
j  Fetus  from  the  Sixth  Month. 
I  Complete  Ovum  from  the  Sixth  Month. 

Fetal  Surface  of  the  Placental  Organs  of  an  Immature 
I  Ovum  in  the  Sixth  Month. 

j  Extrusion  of  the  Placenta  into  the  Cervical  Canal. 
I  Puerperal  Uterus. 

!  Vertical  Sagittal  Section  of  the  Pelvis. 
!  Coronal  Section  through  the  Pelvis, 
i  Arteries  of  the  Genital  Organs. 

Position  of  the  Xon-gravid  L^terus. 
I  Position    of    Fundus    and    Portio   Vaginalis    in    Each 
!  Month  of  Preornancv. 


ILLUSTRATIONS. 


Plate. 

FiGURK. 

20 

34) 

35  . 

36 

21 

37 

38 

22 

39 

40 

41 

23 

42 

43 

44 

45 

24 

46 

47 

48 

25 

49 

50 

51 

26 

52 

53 

54 

27 

55 

56 

57 

28 

58-60  V 
61-63  ] 

29 

30 

64 

65 

66 

67 

31 

68 

69 

32 

70 

71 

72 

33 

73,  74 

34 

75 

76 

35 

77 

78 

79 

36 

80 

81 

37 

82 

83 

External  Examination. 

Vulva  of  a  Primigravida. 

Colchicum-colored  Fornix  of  the  Vagina. 

Usual  Position  of  Portio  Vaginalis. 

The  Head  has  Entered  the  True  Pelvis. 

Antero vertical  Position  of  Portio  Vaginalis. 

Measurement  of  Transverse  Diameter  of  Outlet. 

Accurate  Measurement  of  True  Conjugate  with  the 

Pelvimeter. 
Measurement  of  External  Conjugate. 
Accurate   Measurement  of  Transverse   Diameter  of 

Inlet. 
Palpation  of  Spinec  of  the  Ischium. 
Sagittal  Section  through  a  Petal  Pelvis. 
Sagittal  Section  through  Fully  Dilated  Birth-canal. 
IS'ormal  Female  Pelvis. 
Generally  Equally  Contracted  Pelvis. 
Greatly  Contracted  Funnel-shaped  Pelvis. 
Female  Fetal  Pelvis. 
Sagittal  Section  through  a  Fetal  Pelvis. 
The  Same  in  the  Adult. 

Sagittal  Section  of  Normal  Adult  Female  Pelvis. 
Measurement  of  Transverse  Diameter  of  Inlet. 
Effect  of  Pressure  of  the  Thighs  and  Traction  of  Ilio- 

sacral  Ligaments  on  Shape  of  the  Pelvis. 

Pelvic  Angles  in  Various  Positions. 

Superficial  Layers  of  Uterine  Muscle. 

Deep  Layers  of  Uterine  Muscle. 

Arrangement  of  Muscle-fibers. 

Decidua  Vera. 

Nerve-supply  of  Female  Genitalia. 

Muscles  of  the  Perineum. 

The  Pelvic  Inlet. 

The  "  Principal  Plane  "  of  Veit. 

Plane  of  Pelvic  Expansion. 

Skull  of  a  Child  at  Term. 

Transverse  Section  of  Pelvis  at  Level  of  Internal  Os. 

Rupture  of  the  Cervix  and  Vaginal  Fornix. 

Venous  Plexuses  of  the  Pregnant  Uterus. 

Lymphatics  of  the  Female  Genitalia. 

Secreting  Cells  of  Mammary  Gland. 

Mammary  Gland  of  a  Primigravida  in  the  Seventh 

Month. 
Necrotic  Decidua. 
Lochia  Rubra. 
Lochia  Serosa. 


ILLUSTRATIONS. 


Plate, 

Figure. 

84 

85 

86 

87 

38 

88 

39 

89 

40 

90 

41 

91 

92 

42 

93 

94 

43 

95 

44 

96 

45 

97 

98 

99 

46 

100 

101 

47 

102 

103 

48 

104 

105 

49 

106 

50 

107 

108 

51 

109 

110 

52 

111 

53 

112 

113 

54 

114 

115 

55 

116 

117 

56 

118 

119 

120 

57 

121 

122 

123 

58 

124 

125 

126 

59 

127 

128 

129 

60 

130 

131 

Lochia  Alba. 

Colostrum -cells. 

Milk. 

Section  through  Wall  of  Puerperal  Uterus. 

Mummified  Fetus  with  Ketained  Abortive  Ovum. 

Hydatid  Mole. 

Decidual  Endometritis. 

Decidual  Hemorrhage. 

Subamniotic  "Fibrin."  with  Cysts  and  Extravasation. 

Syphilitic  Inflammatory  Villi. 

Syphilitic  Umbilical  Cord. 

Placental  Infarct. 

Placental  Infarct  in  Eclampsia. 

Uterus  Bicornis  Septus. 

Uterus  Introrsum  Arcuatus. 

Pendulous  Abdomen  of  Third  Degree. 

Twisting  of  Umbilical  Cord  and  Oligohydramnion  of  a 

Dead  Twin. 
Placental  Infarcts. 
Retroflexion  of  a  Gravid  Uterus. 
Partial  Retroflexion  of  a  Gravid  Uterus. 
Hernia  Labialis  Uteri  Gravidi  Bicornis. 
Prolapse  of  Retroflexed  Gravid  Uterus. 
Fibromyoma  of  Lower  L'terine  Segment. 
First  Face  Presentation. 
Subserous  L^terine  Myoma. 
Total  Prolapse  of  Retroflexed  Gravid  Uterus. 
Transverse  Rupture  of  Uterus. 

Gestation  in  Rudimentary  Horn  of  a  Uterus  Unicornis. 
Tubal  Pregnancy. 
Ruptured  Tubal  Gestation-sac. 

Perforation  of  a  Tubal  Sac  into  Bladder  and  Rectum. 
Ovarian  Pregnancy. 
Abdominal  Pregnancy. 
Interstitial  Extra-uterine  Pregnancy. 
Flat  ISTon-rachitic  Pelvis. 
Flat  Rachitic  Pelvis. 

Generally  Contracted  Flat  Rachitic  Pelvis. 
Flat  Rachitic  Pelvis  of  High  Degree. 
Compressed  Rachitic  Pseudo-osteomalacic  Pelvis. 
Compressed  Osteomalacic  Pelvis. 
Zone  of  Ossification  in  a  ISTormal  Epiphysis. 
Zone  of  Ossification  in  a  Rachitic  Epiphysis. 
Section  through  an  Osteomalacic  Bone. 
Conical  Abdomen. 
Pendulous  Abdomen,  First  Degree. 
Pendulous  Abdomen,  Second  Degree. 
Cephalic  Presentation. 
Curve  of  the  Sacrum. 


10 


ILLUSTRATIONS. 


Plate. 

FlOUBE. 

132 

61 

133 

133a 

62 

134 

135 

136 

63 

137 

138 

139 

140 

64 

141 

142 

143 

144 

65 

145 

146 

147 

66 

148 

149 

150 

67 

151 

68 

152  \ 
153/ 

69 

70 

154 

155 

156 

71 

157 

158 

72 

159 

Shape  of  the  Skull. 

Brow  Presentation. 

Hydrocephalus. 

Infantile  Funnel-shaped  Pelvis. 

Rachitic-kyphotic  Funnel-shaped  Pelvis. 

Kyphotic  Funnel-shaped  Pelvis. 

Asymmetrical  Assimilation  Pelvis. 

Double  Promontory  in  Sagittal  Section. 

Obliquely  Contracted  Pelvis. 

Superior  Strait  of  a  Eight  Obliquely  Contracted  Pelvis. 

Right  Obliquely  Contracted  Pelvis. 

Left  Obliquely  Contracted  Pelvis. 

Spondylolisthetic  Pelvis. 

Robert's  Transversely  Contracted  Pelvis. 

Flat  Anteroposteriorly  Contracted  Pelvis. 

Transversely  Contracted  Oval  Pelvis. 

Split  Pelvis. 

Acanthopelys. 

Exoftosis. 

Cystic  Enchondroma. 

Oblique  Presentation  :   "  Conduplicato  Corpore. " 

Complete  Rupture  of  the  Uterus. 

"Face"  Presentation  of  an  Anencephalus. 
Presentation  of  Dicephalus  Dibrachius. 
Presentation  of  Thoracopagus. 

Hydrocephalus  Presenting  with  Head  in  Partial  Flex- 
ion. 
Distention  of  Bladder  and  Ureters. 
Puerperal  Diphtheritic  Endometritis  and  Colpitis. 


PART    1. 

Physiology  and  Dietetics  of  Preg- 
nancy, Labor,  and  the  Puerperium. 


CHAPTER    I. 
PHYSIOLOGY   AND    DIAGNOSIS   OF    PREGNANCY. 

Various  Reasons  for  Determining  the  Exist- 
ence of  Pregnancy. — The  physician  may  be  called 
upon  to  determine  the  existence  or  non-existence  of  preg- 
nancy for  various  reasons.  His  opinion  is  anxiously 
souo^ht  by  those  who  fear  the  possible  consequences  of 
illicit  indulgence,  and  even  in  lawful  wedlock  many  con- 
tingencies arise  whicli  make  it  desirable  or  even  indispen- 
sable to  determine  the  existence  of  pregnancy  and  the  date 
of  its  termination.  The  information  is  asked  for  as  eagerly 
by  the  elderly  couple,  with  an  ardent  desire  for  an  heir 
after  a  long  and  sterile  marriage,  as  by  the  anxious  parents 
blessed  with  a  large  family  but  ill  supplied  with  the  neces- 
saries of  life,  or  by  a  husband  solicitous  for  the  health  of 
his  wife,  whose  constitution  may  be  weakened  by  tubercu- 
losis or  other  disease.  The  date  of  impregnation  is  often 
a  matter  of  great  importance,  as,  for  instance,  when  a 
widow  is  called  upon  to  prove  the  legitimacy  of  her  child 
born  afrer  her  husband's  death  ;  or  for  the  purpose  of 
calculating  the  probable  time  of  delivery,  so  that  it  shall 
not  conflict  with  a  long  sea-voyage  or  a  change  of  resi- 
dence ;  or,  finally,  in  the  case  of  a  late  arrival,  to  enable 

11 


12    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

the  mother  to  make  the  necessary  provisions  for  concealing 
the  fact  from  the  older  children. 

The  early  recognition  of  pregnancy  may  have  an  im- 
portant hearing  on  the  decision  of  a  divorce  suit,  Avhether 
the  wife  be  or  be  not  accused  of  adultery,  and  I  need  not 
in  this  place  enter  into  any  further  discussion  of  the  im- 
portance of  such  a  finding  from  a  medicolegal  point  of 
view. 

In  his  own  interest  the  physician  should  never  allow 
himself  to  forget  the  possibility  of  pregnancy  in  any 
female  patient  who  may  consult  him  for  a  "gynecological'^ 
complaint  of  the  lower  abdomen,  or  even  in  one  who 
presents  marked  pathological  changes  in  the  sexual  organs. 
The  statements  of  such  a  patient  should  always  be  received 
with  skepticism,  as  she  frequently  has  a  reason  for  wishing 
to  deceive  the  physician,  and,  if  possible,  induce  him  to 
undertake  some  intra-uterine  or  other  local  treatment  in 
the  hope  that  he  may  bring  on  an  abortion.  On  the  other 
hand,  there  are  women  who  deceive  themselves,  either  in 
imagining  themselves  pregnant  when  they  are  not,  or 
vice  versa,  according  to  their  temperament  and  desires. 
Before  the  diagnosis  is  finally  settled  and  a  line  of  treat- 
ment decided  upon,  the  question  of  pregnancy  must  be 
determined  by  a  careful  objective  examination. 

Even  an  ordinary  intra-uterine  pregnancy  may  be  very 
difficult  to  recognize  during  the  first  months,  and  in  the 
case  of  a  tubal  or  ovarian  pregnancy  the  diagnosis  is  only 
too  often  quite  impossible,  although  if  it  were  made  early 
it  might,  by  determining  surgical  interference,  prove  the 
means  of  saving  the  patient's  life. 

It  will  be  seen  from  the  foregoing  that  there  is  an  early 
period,  embracing  the  first  two  or  even  three  months, 
during  which  the  existence  of  pregnancy  cannot  be  recog- 
nized with  certainty,  and  a  late  period,  from  the  end  of 
the  third  month  to  term,  when  a  positive  diagnosis  is  in 
ordinary  cases  possible. 

The  Signs  of  Pregnancy. — The  diagnosis,  to  be 
positive,  must  rest  on  the  recognition  of  some  part  of  the 


RELATIVE  VALVE  OE  THE  SIGNS  OE  PREGNANCY.    13 

ovum,  the  fetal  envelo})es,  or  the  fetal  Ixxly  ;  or  on  the 
detection  of  the  cliaracteristic  fetal  symptoms,  especially 
tlie  "fetal  heart-sounds/' about  140  short,  rapid  beats  per 
minute,  resembling  the  muffled  ticking  of  a  watch,  or  the 
soft  "funic  souffle/' heard  synchronously  with  the  fetal 
heart-beats. 

A  knowledge  of  the  anatomical  conditions  is  essential 
in  making  the  diagnosis.     It  is  necessary  to  know  : 

(1)  The  size  and  shape  of  the  fetus  in  the  different 
months  of  pregnancy  ; 

(2)  The  position  of  ovum  and  fetus  in  utero  ; 

(3)  The  changes  in  the  uterus  itself  accompanying 
the  development  of  the  ovum^  and  the  manner  in  which 
these  changes  manifest  themselves  in  the  different 
months ; 

(4)  The  changes  observable  in  other  portions  of  the 
genital  tract ; 

(5)  The  influence  of  pregnancy  on  the  other  organs  of 
the  body. 

Relative  Value  of  the  Signs  of  Pregnancy. — 
The  findings  under  (1),  which  emanate  from  the  child^  are 
called  infallible  signs  of  pregnancy ;  those  under  (3)  and 
(4),  emanating  from  the  maternal  organs,  are  called  prob- 
able signs,  while  those  under  (5),  which  might  be  observed 
in  the  male  as  well  as  in  the  female  subject,  are  classed  as 
unreliable  signs.  The  existence  of  pregnancy  may  be 
considered  more  or  less  probable  according  to  the  number 
of  signs  observed  belonging  to  the  last  two  groups.  They 
acquire  importance  only  when  it  is  impossible  to  elicit  any 
of  the  "  infallible '^  signs,  as,  for  instance,  in  the  first 
month  of  gestation,  or  after  the  death  of  the  fetus,  which 
had  escaped  recognition  by  palpation  on  account  of  its 
small  size  or  marked  malformation.  They  must  be  utilized 
whenever  no  fetal  murmurs  can  be  heard — as  in  cases  of 
polyhydramnios,  in  myxomatous  degeneration  of  the  ovum 
(so-called  vesicular  mole),  in  the  case  of  a  co-existing 
tumor,  or  in  ectopic  gestation. 

The  detection  of  many  of  these  "probable"  and  "un- 


14    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  1.  Ovary  with  Ampulla  of  Tube.— The  fimbriated  extremity  of 
the  tube,  loosely  held  iu  place  by  the  ovariopelvic  fold  of  peritoneum,  is 
attached  to  the  broad  ligament,  although  less  firmly  than  the  isthmus. 
The  gaping  morsus  diahoU  is  seen  with  a  stalked  hydatid  hanging  from 
it;  a  small  cyst  is  also  seen  on  the  fimbria  ovarica.  These  structures  are 
present  in  four-fifths  of  all  individuals  and  represent,  when  situated  in 
the  anterior  layer  of  the  broad  ligament,  the  atrophic  remains  of  the 
transverse  tubules  of  the  lower  part  of  the  Wolffian  body ;  or  they  may 
be  pedunculated  fimbriae  covered  with  epithelium.  The  surface  of  the 
ovary  is  grayish-red  and  presents  on  its  upper  margin  a  structure  of 
similar  appearance,  which  is  a  Graafian  follicle,  while  several  deeper  lying 
follicles  can  be  made  out  by  their  bluish  color  shining  through  the  tunica 
albuginea.  The  furrows  represent  the  scars  of  follicles  which  have  burst 
and  been  converted  into  corpora  fibrosa  or  candicantia.  The  upper  border 
of  the  ovary  is  covered  by  peritoneum,  or  rather  embedded  in  a  fold  of 
the  membrane;  the  boundary,  known  as  Farre's  line,  can  be  seen  in  the 
figure  (original  water-color,  natural  size). 

Fig.  2.  Ovary  with  Corpus  Luteum  (original  water-color,  natural  size) 
laid  open;  underneath,  a  cyst  laid  open,  with  myoma  of  the  uterus. 
The  follicle,  which  may  attain  the  size  of  a  pea,  is  ruptured  by  the  inter- 
nal pressure  at  the  time  of  the  menstrual  congestion,  the  ovum  escaping 
into  the  peritoneal  cavity.  The  follicle  then  becomes  filled  with  clotted 
blood  and  large  cellular  elements  containing  fat  and  a  yellow  pigment — 
the  lutein-cells,  derived  from  the  follicular  epithelium,  or,  according  to 
others,  from  the  granular  cells  of  the  internal  tunic  {membrana  granulosa), 
and  is  then  called  a  corpus  luteum.  It  is  often  traversed  by  radiating 
connective-tissue  septa,  and  the  center  is  occupied  by  coagulated  blood, 
which  may  persist  a  long  time  and  contain  hematoidin  crystals. 

Fig.  3.  Longitudinal  Section  of  an  Ovary  (original  water-color,  natural 
size),  showing  the  cortcr.,  in  which  Graafian  follicles  in  various  stages  of 
development  are  embedded,  and  the  medulla.,  richly  supplied  with  blood- 
vessels. The  outermost  laj^er  is  formed  by  the  fibrous  tunica  albuginea, 
covered  with  cuboidal  epithelial  cells. 


reliable"  sig-ns  of  pregnancy  must  be  learned  by  constant 
practice,  and  the  search  for  them  should  never  be  neglected. 
If  the  physician  has  had  an  opportunity  of  examining  the 
patient  before  she  became  ])regnant  the  diagnosis  is,  of 
course,  much  easier,  as  the  size,  position,  and  consistency 
of  the  unimpregnated  uterus  are  known.  During  the 
first  month  the  picture  of  a  normally  progressing  preg- 
nancy is  obtained  by  comparing  the  changes  observed  at 
two  successive  examinations  made  at  an  interval  of  three 
to  four  weeks. 


jO 

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V 


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DF^VELOPMEXT  OF  THE   OVUM.  15 

These  changes  affect  the  shape,  size,  blood- supply,  con- 
sistency, color,  and  specific  functions  of  the  organs. 

§1.  DEVELOPMENT  OF  THE  OVUM.  CHANGES  OBSERVED 
IN  THE  ORGANS  OF  GESTATION  DURING  PREGNANCY. 

The  ovary,  in  which  the  ova  are  formed,  is  an  almond- 
shaped  organ,  measuring  from  IJ  to  2  in.  (3  to  5  cm.)  in 
length,  partially  covered  by  a  fold  of  peritoneum,  the 
mesovarium,  and  embedded  in  the  posterior  layer  of  the 
broad  ligament.  It  is  attached  to  the  uterus  by  means 
of  the  ovarian  Ugamentj  and  to  the  Fallopian  tube  or 
oviduct  by  means  of  the  fimbriae,  which  are  covered  with 
ciliated  epithelium  and  form  part  of  the  tubo -ovarian 
ligament.  The  pull  of  this  ligament  gives  to  the  ampulla, 
which  is  freely  movable,  a  downward  curve,  so  as  to  bring 
its  opening,  the  morsus  diaboli  or  ostium  abdominale,  nearer 
the  ovary.  The  free  portion  of  the  tubo-ovarian  ligament, 
together  with  the  curved  tubal  portion  of  the  broad  liga- 
ment, yv'iih  which  it  is  continuous,  forms  a  tent-like  cover- 
ing for  the  ovary — the  ovarian  sac  (bursa  ovarii). 

The  ovary  is  usually  found  below  the  pelvic  inlet,  in  a 
sagittal  plane  midway  between  the  superior  spine  of  the 
ilium  and  the  symphysis,  corresponding  in  height  and 
direction  to  the  iliopectineal  line  at  its  center  (AValdeyer), 
and  embedded  in  the  posterior  portion  of  the  obturator 
fossa.  It  is  surrounded  by  the  ureter,  the  internal  iliac, 
and  uterine  arteries,  and  lies  within  the  fossa  ovarii,  which 
occupies  the  posterior  ])art  of  the  lateral  wall  of  the  pelvis 
near  the  margin  of  the  sacrum.  At  this  point  it  is 
attached  by  the  suspensory  ligament  of  the  ovary,  the 
inffimJibuIopelvic  band,  which  transmits  the  ovarian  vessels. 
The  vermiform  appendix  usually  descends  as  far  as  this 
region,  being  sometimes  connected  with  the  oviduct  by  a 
narrow  fold  of  peritoneum,  the  plica  ovarico-enterica. 

The  surface  of  the  ovary  (Fio:s.  4  and  5)  is  covered  with  a  single 
layer  of  cuboidal  epithelial  cells,  derived  from  the  same  source  as 
the  large  endothelial  cells  of  the  peritoneal  covering,  although 
there  is  a  distinct  boundary-line  between  them.     In  the  third 


16    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  4.  Transverse   Section  of  Ovary  from  a  Four-months'   Fetus 

(microscopical :  original  drawing  from  author's  specimen). — Explanation 
of  numbers  as  in  Fig.  .5. 

Fig.  5.  Longitudinal  Section  through  the  Ovary  of  a  New-horn  Infant, 
showing  a  Mature  Follicle  (niicioscopical ;  original  drawing  from  au- 
thor's specimen) :  1,  sharply  outlined  endothelial  cells  at  hilum,  merging 
into  2,  cuboidal  germinal  epithelium  ;  .3,  an  ovum  embedded  in  the  follic- 
ular epithelium,  which  is  derived  from  germinal  epithelium  by  prolifera- 
tion of  Pfliiger's  cell-cords,  showing  zona  pellacida,  yolk,  germinal  vesicle, 
and  germinal  spot ;  4,  follicle  lined  with  a  single  layer  of  epithelium  and 
containing  one  ovum  ;  7,  one  with  two  ova;  5,  capillaries;  6,  primitive 
ova;  8,  fully  matured  Graafian  follicle,  showing  the  fibrous  theca  follicuU, 
membrana  gramdosa,  discus  proligerus,  ovum,  and  liquor  foUicnli,  which  is 
seen  pushing  the  surface  of  the  ovary  upward  ;  9,  immature  follicle  with 
ovum.  The  other  spaces,  lined  with  a  single  layer  of  cuboidal  cells, 
represent  follicles  in  which  the  ovum  did  not  happen  to  be  included  in 
the  section.  10,  blood-vessels,  lymphatics,  and  nerves  entering  the  hilum 
from  the  broad  ligament  in  company  with  the  intraligamentary  connec- 
tive tissue. 

Fig.  6.  Cross-sections  of  an  Oviduct  (microscopical ;  original  draw- 
ing from  author's  specimen) :  a,  near  the  ostium  internum,  which  is  rich  in 
muscle-fibers,  the  mucosa  has  few  papillae  ;  b,  through  the  isthmus,  four 
papillfe  in  mucosa ;  c,  near  the  ampulla,  poor  in  muscle-fibers,  but  rich 
in  papillfe;  1,  peritoneal  endothelium;  2,  subserous  connective  tissue 
with  blood-vessels  (4) ;  3,  muscularis.  essentially  circular  in  shape  ;  5, 
ciliated  epithelium. 

Fig.  7.  Cross-section  through  the  Isthmus  of  a  Gravida  (microscopical ; 
original  drawing  from  author's  specimen):  1,  endothelium;  2,  subserous 
connective  tissue  containing  numerous  blood-vessels;  .3,  muscular  coat 
with  markedly  dilated  vessels,  as  at  4.  for  instance,  where  the  vessel 
appears  in  oblique  section;  5,  columnar  epithelium  which,  with  the 
stroma,  forms  the  characteristic  papillae  appearing  in  the  fifth  month. 

month  of  fetal  life  this  germinal  epithelium,  as  it  is  called,  begins 
to  proliferate,  and  dips  down  into  the  loose  connective-tissue 
stroma  of  the  cortex  in  the  form  of  Pfliiger's  cell- cords,  after 
traversing  the  thickened  outer  layer  of  stroma  known  as  the  tunica 
alhuginea.  The  ova  develop  within  the  true  ovarian  stroma.  In 
their  primitive  stage  they  appear  among  the  cuboidal  epithelial 
cells  as  large  cellular  elements  with  a  nucleus  and  nucleolus,  later 
as  globular  masses,  consisting  of  germinal  epithelium  and  several 
primitive  ova,  pushing  their  way  into  the  stroma.  From  these 
masses  are  formed  the  primary  follicles  in  which  each  ovule  has 
separated  from  the  mass  and  become  surrounded  by  small  epithe- 
lial cells  derived  from  the  walls  of  the  follicle.  The  latter  finally 
develops  into  the  mature  Graafian  follicle.     By  proliferation  of 


Tab.     2. 


Fig.  5. 


Fig.  6. 


Fig    7. 

Lith.Anst  F.  Ruduwld.  Mimchjen. 


DKVFAJJPMENT  OF   THE  OVUM.  17 

the  follicular  epithelium  the  zona  r/ranulosa,  and  later,  the  discus 
proligerus,  are  formed,  within  which,  situated  near  one  pole,  the 
mature  ovum  is  formed.  The  ovum  now  consists  of  the  radially 
striated  zona  pellucida,  yolk,  germinal  vesicle,  and  germinal  spot, 
entangled  in  the  meshes  of  chromatin-fibers.  Inside  the  zona 
gramdosa  the  discus  proligerus  is  surrounded  by  the  liquor  folliculi, 
which  separates  it  from  the  wall  of  the  follicle.  The  follicle  is 
covered  by  a  layer  of  greater  density,  the  fheca  foUieuli  or  tunica 
propria  et  fibrosa.  Xerves  have  been  found  in  the  discus  proligerus. 
Xo  D-anglion-cells  have  as  vet  been  demonstrated  in  the  ovarv 
(v.  Herff ). 

The  center  of  the  ovary  is  occupied  by  the  medulla,  the  stroma 
of  w^hich  is  richly  supplied  with,  blood-vessels  and  nerves  derived 
from  the  intraligamentary  connective  tissue. 

OVULATION   AND   MENSTRUATION. 

The  ovaries  are  at  all  times  filled  with  ova  in  various 
stages  of  development.  An  overdistended  Graafian  folli- 
cle bursts  and  an  ovum  is  discharged.  Two  or  more 
follicles  may  rupture  at  the  same  time  and  give  rise  to  a 
twin  or  multiple  pregnancy,  or  the  fecundation  of  more 
than  one  ovum.  The  overdistention  and  rupture  of  a 
Graafian  follicle  are  caused  by  an  increase  in  the  blood- 
pressure  within  the  ovary,  which  occurs  at  intervals  of 
three  to  four  weeks,  hence,  under  normal  conditions,  the 
escape  of  the  ovum  into  the  peritoneal  cavity  recurs  at 
regular  periods  coincident  Avith  the  time  of  greatest  blood- 
pressure.  The  pressure  begins  to  rise  about  the  middle 
of  the  intermenstrual  period,  hence,  even  at  this  time,  any 
accidental  congestion  of  the  generative  organs  may  bring 
about  the  distention  and  rupture  of  a  follicle.  It  has  been 
proven  by  postmortem  studies  on  pregnant  women  who 
had  died  of  heart  disease,  that  this  periodical  determina- 
tion to  the  generative  organs  continues  during  pregnancy  ; 
the  rupture  of  a  follicle  during  this  period  is,  therefore, 
possible,  and  explains  the  occurrence  of  superfecundation 
or  impregnation  of  an  ovum  after  the  development  of  an 
embryo  has  begun,  and  even  of  superfetation  (after  the 
sixth  week).^ 

^  This  is  denied  bvmost  American  authorities  ;  see  Piersol,  in  American 
Text-BooJ:  of  Obstetrics,  p.  144.— Trans. 

2 


18    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

The  escape  of  the  ovum  from  tlie  ovary  is  termed  ovula- 
tion; while  the  regularly  recurring  determination  of  blood 
to  the  generative  organs  has  received  the  name  of  menstru- 
ation, because  it  occurs  usually  at  intervals  of  about  four 
weeks.  Both  processes  are  evidently  under  the  control 
of  a  central  regulating  apparatus ;  for,  although  the  local 
hemorrhage  from  the  genitalia  is  the  most  conspicuous 
pathological  feature,  the  entire  organism  not  only  during 
the  three  or  four  days  of  the  catamenial  period  but  also 
during  the  entire  space  of  four  weeks  is  subjected  to 
fluctuations  in  blood-pressure,  metabolism,  and  innervation, 
culminating  in  the  establishment  of  the  menstrual  flow. 
Thus  the  determination  to  the  generative  organs  is  a  grad- 
ual process,  starting  about  the  middle  of  the  intermenstrual 
period  and  culminating  in  a  local  hemorrhage  from  the 
congested  mucous  membrane  of  the  uterus.  If  the  escap- 
ing ovum  is  not  fertilized,  the  congestion  of  the  mucous 
membrane  and  the  active  regenerative  processes  in  its 
epithelial  and  glandular  structures  subside,  the  parts  re- 
turn to  their  former  condition,  and  the  epithelium  of  the 
mucous  membrane  separates  here  and  there  in  shreds  over 
the  site  of  submucous  ecchymoses.  This  disintegrating 
process  usually  occupies  about  two  weeks. 

Metal^olic  activity  is  at  its  height  shortly  before  the 
menstrual  period,  sinks  as  soon  as  the  catamenial  flow  is 
established,  and  continues  at  its  lowest  during  the  three 
or  four  days  of  the  menstrual  period.  The  changes  in 
the  other  generative  organs  are  undoubtedly  dominated 
by  the  ovarian  process ;  without  the  latter  there  can  be  no 
menstruation.  Artificial  congestion  of  the  ovaries  by 
injection  is  followed  by  hyperemia  of  the  uterine  raucous 
membrane  (Strassmann). 

The  ovaries  can  be  transplanted  in  the  same  animal  to  other  por- 
tions of  the  peritoneal  cavity  without  suffering  any  impairment  of 
function  ;  they  continue  to  share  in  the  congestion  of  the  uterus, 
and  may  even  inaugurate  a  normal  pregnancy  (Knauer). 

On  the  other  hand,  if  both  ovaries  are  removed  the  uterus 
undergoes  atrophy  and  the  blood-vessels  degenerate,  the  epithelial 
and   glandular   portions   of  the   mucous   membrane  being   first 


DEVELOPMENT  OF  THE  OVUM.  19 

affected.     The   ovaries   also   undergo   retrograde   metamorphosis 
after  extirpation  of  the  uterus. 

In  a  sense  the  ruptured  follicles  also  share  in  the  men- 
strual hemorrhage.  If  impregnation  has  occurred  the 
hemorrhage  within  the  follicle  is  more  marked  and  the 
ovaries  become  enlarged  and  succulent.  After  the  escape 
of  the  ovum  the  cells  lining  the  inner  surface  of  the  fol- 
licle (follicular  epithelium  or  the  granular  cells  of  the 
internal  tunic)  undergo  proliferation  and  fatty  change, 
there  is  an  invasion  of  round  cells,  and  a  yellow  body, 
the  corpus  luteum  {verum),  is  formed. 

The  wall  of  the  follicle  separates  in  folds,  hematoidin-crystals 
are  deposited,  the  entire  mass  becomes  organized,  and  the  prolif- 
eration of  connective  tissue  forms  a  scar — corpus  fibrosum  s.  ccmdi- 
dans.  The  corpora  lutea  appear  to  be  concerned  with  the  main- 
tenance of  normal  circulation  and  blood-pressure  within  the 
ovary. 

Tubal  menstruation  may  occur  in  certain  pathological 
conditions. 


FERTILIZATION    AND  PROPULSION   OF  THE   FERTIL- 
IZED  OVUM   ALONG  THE  OVIDUCT. 

When  the  ovum  reaches  the  peritoneal  cavity  it  is 
carried  toward  the  pavilion  of  the  oviduct  partly  by  the 
ciliary  movement  of  the  fimbriae  and  partly  by  the  current 
of  the  thin  layer  of  serous  fluid  which  normally  covers 
the  entire  peritoneum.  This. current  is  produced  by  a 
sucking  action  emanating  from  the  ampulla,  the  mucous 
membrane  of  which  is  free  from  glands  and  consists  of  a 
substratum  of  longitudinal  bundles  of  connective  tissue 
containing  numerous  round  cells,  surmounted  by  a  layer 
of  short  ciliated  columnar  cells,  which  generate  a  ciliary 
current  toward  the  narrow  ostium  internum.  The  same 
current  effects  the  removal  of  a  non-impregnated  ovum. 
If  fecundation  has  occurred,  the  muscular  fibers  of  the 
tube  also  assist  in  the  propulsion  of  the  ovum.  It  is 
possible  for   an  ovum   to  find   its   way  into   the   opposite 


20    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  S.  Embryo  from  an  Abortion  at  the  End  of  the  Second  Month 
(original  water-color,  natural  size). — The  decidua  shows  numerous  ex- 
travasations ;  the  chorion,  which  is  held  up  and  expanded,  is  detached  in 
places.  Through  the  opening  a  view  of  the  interior  of  the  amniotic  sac 
is  obtained,  showing  the  umbilical  cord  and  several  subamniotic  hema- 
tomata.  The  ovum  must  have  been  ruptured  during  labor  and  the 
embryo  expelled  with  the  amniotic  fluid,  unless,  as  happens  frequently 
in  early  abortions,  the  embryo  died  first  and  was  absorbed. 


tube  either  by  external  or  intraperitoneal  or,  in  rare  cases, 
by  internal  uterine  transmigration. 

It  follows  from  the  foregoing  description  that  the  oviduct  may 
be  divided  into  two  segments:  the  uterine  idhmus  with  a  very 
narrow  lumen,  lined  with  smooth  mucous  membrane,  but  possess- 
ing a  robust  muscular  layer,  and  the  ampulla,  of  a  much  larger 
caliber  and  provided  with  a  thickly  corrugated  mucous  mem- 
brane. From  the  folds  of  this  membrane  are  formed  the  morsm 
dlaboli  and  the  fimbriae  which  surround  the  ostium  abdominale. 
The  fimbriae  begin  to  appear  in  the  third  or  fourth  month  of  fetal 
life.  At  this  time  the  extremities  of  the  tubes  are  partly  united 
with  the  surface  of  the  ovary,  forming  the  so-called  ovarian  tubes, 
which  occasionally  persist  and  may  give  rise  to  a  tubo-ovarian 
gestation. 

In  transverse  sections  the  lumen  of  the  tube  presents  a  stellate 
outline  (Figs.  6  and  7).  At  the  uterine  extremity  there  are  three 
papillary  projections;  in  the  intermediate  portion  four  primary 
and  several  secondary  papillae,  the  former  appearing  as  early  as 
the  fifth  month  and  containing  numerous  unstriated  muscle-fibers, 
while  the  entire  lumen  of  the  ampulla  is  filled  with  richly 
branched  processes.  There  are  no  actual  mucous  glands,  but  in 
health  the  surface  is  constantly  bathed  with  a  small  amount  of 
mucus  secreted  by  the  cells  of  the  mucous  membrane. 

The  inusciilaris  mucosw  is  composed  of  a  robust  median  zone  of 
circular,  and  a  lesser  external  zone  of  longitudinal,  fibers.  The 
tube  is  covered  with  peritoneum  for  three-fourths  of  its  circum- 
ference, the  remaining  fourth  corresponding  to  the  hilum.  The 
latter  is  formed  by  intraligaraentary  connective  tissue  which  con- 
tains tlie  blood-vessels  and  surrounds  the  entire  tube  under  the 
peritoneal  covering. 

Impregnation  may  occur  at  any  point  in  the  oviduct. 
By  virtue  of  their  ciliary  movement  the  spermatic  fila- 
ments are  able  to  reach  the  fundus  uteri  within  a  few 
hours,  and  they  retain  their  vitality  a  week  or  more  after 
coitus,  in   the  uterus,  in  the  tubes,  or  even  on  the  peri- 


Tab.     3. 


Fig    8. 


LUh.  Ami  E  ReUhhold.  Mimchen 


DEVELOPMENT  OF  THE  OVUM.  21 

toneum.  The  chances  of  fertilization  are  greatly  enhanced 
by  the  circumstance  that  the  ovum  and  spermatic  filament 
travel  the  same  path,  and  by  the  enormous  number  of 
the  latter  discharged  at  one  ejaculation.  Impregnation 
probably  takes  place  most  frequently  in  the  ampulla. 

DEVELOPMENT  OF  THE  EMBRYO  AND  FETAL  MEM= 

BRANES. 

Several  spermatic  filaments  may  enter  the  ovum ;  the  nucleus 
of  one  of  these  blends  with  the  female  pronucleus,  which  remains 
after  the  extrusion  of  the  polar  bodies.  The  extrusion  occurs 
whether  the  ovum  is  fecundated  or  not.  A  small  mass  of  pro- 
toplasm enters  the  ovum  along  with  the  male  pronucleus  and  the 
zona  pellucida  is  formed,  enclosing  the  ovum  in  a  denser  envelope. 
The  process  of  segmentation  now  begins  and  results  in  the  forma- 
tion of  the  blastodei^mic  vesicle,  presenting  a  field  of  greater  den- 
sity, which  marks  the  first  indication  of  the  embryonal  area.  By 
the  sinking  in  of  this  embryonal  area  the  blastula  becomes  con- 
stricted and  divides  into  two  portions,  connected  by  the  ductus 
omphalomesaraicus.  The  blastula  now  consists  of  two  layers:  the 
ectoderm  and  the  entoderm.  From  the  former  are  derived  the 
skin,  the  nervous  system,  and  the  organs  of  special  sense;  from 
the  latter,  the  epithelial  structures  (glands)  of  the  intestines. 
Between  these  two  layers  and  springing  from  both  is  the  mesoderm, 
which  later  develops  into  the  vascular  system,  connective  tissues, 
muscles,  and  sexual  organs.     The  ectoderm  is  the  first  to  appea-r. 

After  the  formation  of  the  primitive  groove  the  medul- 
lary folds  begin  to  rise  on  either  side  of  the  medullary 
furrow.  Even  before  thev  unite  and  close  in  the  medul- 
lary  canal,  the  embryo  becomes  completely  enveloped  in 
a  sac  filled  with  fluid — the  amnion — which  grows  back- 
Avard  from  the  ununited  body  walls,  surrounds  the  em- 
bryo, and  unites  behind,  in  a  line  parallel  with  the  dorsal 
folds.  At  first  closely  adherent  to  the  ectoderm,  the 
amnion  gradually  separates  as  the  amniotic  fluid  is  formed. 
This  separation  is  effected  before  the  fourteenth  day,  when 
the  embrvo  is  from  i  to  li  in.  (2  to  3  cm.)  long;. 

The  zona  pellucida,  the  striations  of  which  are  due  to 
the  presence  of  intercellular  processes  running  from  the 
ovum  to  the  cells  of  the  follicular  epithelium,  now  be- 
comes converted  into  a  membrane  provided  with  numer- 


22    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  9.  Clioiioii  and  Amniotic  Sac  with  Ovum,  between  the  Second 
and  Third  Month  (uiiginal  water-color).— The  chorion  ifrondosum),  which 
at  this  period  still  surrounds  the  entire  ovum,  is  laid  open,  showing  the 
interior  of  the  aniuiotie  sac  and  the  head  of  the  embryo. 

Fig.  10.  Decidua  Vera  (original  water-color,  see  Fig.  8).— A  portion 
of  it  is  still  intact  and  covered  with  blood-clots.  Compare  these  true 
fetal  membranes  with  : 

Fig.  11,  which  represents  spurious  fetal  remains,  consisting  of  fibrin 
and  blood-clots. 

Fig.  12.  Complete  Ovum  in  the  Second  Month  (original  drawing  from 
a  specimen  obtained  at  the  Miinich  Gynecological  Clinic). — The  "win- 
dow" in  the  decidua  vera  reproduces  the  triangular  shape  of  the  uterus; 
/.  M.,  OS  uteri ;  o.t.,  openings  of  the  oviducts.  We  see  the  decidua  reflexa 
{D.c),  the  chorion  {Ch),  and  within  the  amuion  {Am)  the  embryo  (brain - 
vesicles,  visceral  arches,  four  extremities,  prominence  of  cardiac  and 
hepatic  regions,  and  the  caudal  extremity  with  the  long  coccygeal 
point). 

Fig.  13.  Ovum  of  the  Third  Month  (original  drawing).— We  see  de- 
cidua reflexa  {D.c),  the  chorion  (Ch)  laid  open,  and  the  amnion  {Am) 
closed.  The  fetus  h  suspended  by  the  umbilical  cord  [Xah.).  which  is 
seen  through  the  membranes.  Tlie  head  is  large  in  comparison  with  the 
body. 


ous  villi,  consisting  principally  of  ectoderniic  cell-cords 
which  bind  it  firmly  to  the  amnion.  It  is  fnrtlier  attached 
to  the  embryo  by  means  of  an  abdominal  stalk,  the  future 
umbilical  cord.  Through  this  structure  the  embryo 
obtains  its  nutriment  by  means  of  vessels  which  at  first 
derive  their  material  from  the  vitelline  circulation  {arterice 
et  vencE  omphalomesaraicce),  as  they  form  a  network 
around  the  vitelline  sac.  The  remains  of  this  structure 
are  sometimes  found  at  birth  as  a  minute,  flat,  yellowish 
mass  not  far  from  the  insertion  of  the  cord  into  the  pla- 
centa, along  one  of  the  folds  of  the  amnion  (B.  S.  Schultze). 
About  the  middle  of  the  first  month  the  aUantoic  sac 
makes  its  appearance  at  the  caudal  pole  of  the  embryo, 
growing  from  the  region  of  the  hind-gut  and  urachus. 
It  contains  the  umbilical  vessels  which  dip  down  into  the 
branching  ectodermic  blood-islands  of  the  chorion.  The 
umbilical  cord  breaks  up  into  the  countless  chorionic  villi 
of  the  placenta.  The  latter  push  their  way  into  the  uter- 
ine mucous  membrane,  which  is  denuded  of  its  epithelial 


>^.S#'''' 


ik>  K-M^ 


M:>-. 


^ 


LMi 


WS^ 


DEVELOPMENT  OF  THE  OVUM.  23 

coverino;  or  soon  becomes  so  by  the  ingrowth  of  the  villi, 
and  into  the  capillarie.^,  whose  endothelial  lining  also  dis- 
appears;  the  capillaries  between  the  villi  become  greatly 
enlarged  and  filled  w^ith  blood,  constituting  the  intervillous 
spaces.  Here,  by  a  process  of  osmosis  and  an  interchange 
of  gases,  the  nutrition  and  respiration  of  the  embryo  is 
effected ;  it  is  the  so-called  allantoic  circulation  which 
persists  till  birth,  is  subject  to  the  pressure  of  the  uterine 
vessels  in  the  chorionic  villi,  and  is  maintained  by  the 
action  of  the  fetal  heart.  The  villi  are  covered  by  a 
sino^le  laver  of  ectodermic  cells,  the  forerunners  of  the 
protoplasmic  nucleated  syncytial  cells  by  which  the  nutri- 
ment and   maternal  albumin  are  conveyed  to  the  embryo. 

At  first  the  chorion  surrounds  the  embryo  in  its  entire 
circumference  (see  Figs.  9  and  12).  Until  the  end  of  the 
first  month  the  chorion  measures  |-  in.  (2  cm.)  in  diame- 
ter ;  the  length  of  the  embryo  is  less  than  |-  in.  (1  cm.), 
about  J  to  -J-  in.  (7  to  8  mm.)  ;  the  cephalic  flexure  is 
fully  developed.  In  the  brain  it  is  possible  to  distinguish 
the  beginnings  of  the  cerebral  hemispheres  from  the  mid- 
brain ;  the  limb-buds  are  present ;  the  liver  begins  to 
appear  as  a  distinct  prominence,  which  later  can  be  plainly 
seen  from  the  outside. 

The  chorion  is,  therefore,  a  fetal  envelope  of  embryonal 
origin.  It  is  in  turn  enclosed  in  a  product  of  the  uterine 
mucous  membrane — the  decidua  reflexa  (or  circumflexa) — 
called  deciduous  because  cast  off  and  becoming  useless  at 
birth.  The  decidua  vera  (Figs.  8,  12,  67,  a  and  h)  is 
simply  the  hypertrophied  and  vascular  uterine  mucous 
membrane  of  pregnancy,  which  extends  as  far  as  the 
internal  os,  or,  in  rare  cases,  a  few  centimeters  into  the 
cervical  canal.  Another  fold  of  mucous  membrane,  iden- 
tical in  structure,  is  thrown  around  the  free  convex  border 
of  the  chorion  which  ])rojects  into  the  cavity  of  the  uterus, 
opposite  its  point  of  attachment  to  the  uterine  mucous 
membrane.  This  maternal  envelope  has  received  the  name 
of  decidua  reflexa. 

Judging  from  comparative  investigations  on  animals,  it 


24    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  14.  Transverse  Section  of  the  Uterus  from  a  Six-months'  Fetus 
(microscopical ;  original  drawing  from  authors  specimen)  at  the  level  of 
the  internal  os :  1,  single  layer  of  cylindrical  ciliated  epithelium,  secreting 
mucus,  with  primitive  glandular  depressions;  the  S-shaped  lumen  is 
characteristic  of  the  cervical  portion  of  the  uterus,  and  depends  on  the 
plicx  palmate,  or  dendritic  folds  of  the  cervical  canal  {arbor  vitie) ;  2,  con- 
nective-tissue stroma  of  the  mucous  membrane,  containing  many  round 
cells,  especially  under  the  epithelium,  and  traversed  by  blood-vessels;  3, 
bundles  of  muscular  tissue,  the  tibers  are  for  the  most  part  obliquely 
circular  with  arteries  radiating  among  them  :  4,  subserous  connective  tissue 
through  which  the  arterial  trunks  make  their  way  from  6,  the  intraliga- 
laentary  connective  tissue  containing  the  main  j^ranches  of  the  uterine 
artery;  scattered  here  and  there  are  single  bundles  of  muscle-fibers  in 
transverse  section;  5,  peritoneal  endothelium. 

Fig.  15.  Cells  from  Decidua. 

Fig.  16.  Chorionic  Villus  with  Fetal  Blood-vessels  (microscopical ; 
original  drawing  from  teased  preparation). — Embryonal  mucous  connec- 
tive tissue  covered  with  a  protoplasmic  baud  containing  nucleus  (as  de- 
scribed in  the  text)  and  fetal  blood-vessels.  (Xote. — According  to  the 
latest  discoveries  the  cuboidal  epithelium  with  the  cross-markings  is 
found  only  during  the  first  two  weeks.) 


appears  most  probable  that  the  ovum  '^  eats  its  way,"  so 
to  speak,  into  the  decidua  by  means  of  the  chorionic  villi, 
or,  as  V.  Herff  expresses  it,  ^'builds  a  nest  for  itself"  in 
the  hypertrophied  decidna.  This  type  is  seen  in  Sanger's 
ovum  from  a  tubal  pregnancy  of  two  and  a  half  weeks, 
examined  by  Fiith. 

The  mucous  membrane  of  the  uterus,  as  is  to  be  expected 
from  the  complex  nature  of  its  functions,  is  a  much  more 
highly  specialized  organ  than  any  other  mucous  membrane 
in  the  body. 

In  the  primitive  form  (Fig.  14),  as  seen  in  the  new-born,  the 
lumen  of  the  uterine  body  presents  in  transverse  section  a  curved 
slit  with  its  convexity  looking  backward,  lined  with  a  single  layer 
of  columnar  epithelium  and  sending  hut  few  processes  into  the 
submucous  stroma— the  forerunners  of  the  complicated  mucous 
glands  which  develop  later,  especially  in  the  cervical  canal.  The 
vascular  system  in  the  submucosa  is  well  developed  even  at  this 
early  date,  the  ramification  of  the  capillaries  being  quite  pro- 
nounced. The  arterial  trunks  ])ass  almost  vertically  through  the 
circular  and  oblique  fibers  of  the  muscularis,  hence  in  adults  the 
arteries  are  completely  closed  by  violent  or  tetanic  contractions, 


:o 


OS 

Eh 


^ 


0 
i 

I  n 


-^    .r 


DEVELOPMENT  OF  THE  OVUM.  25 

and  even  moderate  contractions  may  compress  them  to  a  consider- 
able extent.  Muscular  contractions  may  be  vigorous  enough  to 
cut  off' the  sup}»ly  of  blood,  and,  therefore,  of  oxygen  to  the  fetus; 
while,  on  the  other  hand,  they  may  be  utilized  as  a  means  of 
stopping  an  uncontrollable  hemorrhage. 

Anatomically  the  uterus  is  naturally  divided  into  two 
parts  :  the  hodij^  which  in  the  virgin  state  is  flattened  and 
about  the  size  and  shape  of  a  pear ;  and  the  cylindrical 
cervix,  narrower  than  the  body,  the  conical  extremity  of 
which  projects  into  the  vagina,  and  thus  justifies  the  name 
portio  vaginalis. 

The  cervical  canal  communicates  with  the  vagina  by 
means  of  the  external  os.  Its  chief  function  is  the  secretion 
of  alkaline  mucus,  which  has  marked  beictericided  quali- 
ties and  serves  to  lubricate  the  vagina.  It  is  possible  that 
the  mucous  plug  which  occludes  the  cervix  may  in  some 
way  facilitate  impregnation.  The  intermediate  portion 
of  the  cervical  canal  is  somewhat  dilated  and  contains  the 
plicce  palmatce  {arbor  vitce),  which  in  the  fetal  uterus  form 
obliquely  placed  valves  similar  to  those  observed  in  the 
sheep. 

The  columnar  epithelial  cells  secrete  mucus  and  are  accordingly 
very  well  developed.  The  club-shaped  cells  of  the  cervix  are  the 
best  developed  of  any  in  the  body  ;  the  lower  protoplasmic  portion 
containing  the  nucleus  elaborates  the  mucus,  which  is  stored  for  use 
in  the  upper  portion  of  the  cell.  The  cells  are  provided  with  cilia 
which  generate  a  current  directed  from  the  fundus  to  the  cervical 
canal  (Hofmeier,  Mandl).  The  shape  of  the  cells  is  strongly 
influenced  by  external  conditions.  Between  the  cells  are  preformed 
intercellular  spaces  traversed  by  delicate  fibrils  of  protoplasm. 

The  cervical  canal  communicates  with  the  cavity  of  the 
uterus  by  means  of  the  narrow  and  sensitive  interned  os, 
which  is  occasionally  closed  l)y  valves  directed  toward  the 
fundus,  the  remains  of  infantile  structures.  Under  normal 
conditions  the  ovum  is  attached  above  the  internal  os, 
hence  the  uterine  cavity  represents  the  specialized  segment 
destined  for  the  reception  and  development  of  the  ovum.  The 
mucous  membrane  of  the  corpus  uteri  only  becomes  con- 
verted into  the  decidua,  and  the  menstrual  hemorrhage  is 


26    PHYSIOLOGY  AND  DIAGNOSIS;  OF  PREGNANCY. 

Fig.  17.  Rare  Vertical  Position  of  the  Gravid  Uterus  in  the  Third 
Month,  following  a  Retroversion  (original  drawing). — Sagittal  section 
through  the  median  line  of  the  pelvis.  The  ovum  does  not  extend  below 
the  body  of  the  uterus;  the  cervical  canal  and  both  the  internal  and  the 
external  os  are  closed.  The  external  os  is  directed  downward  and  back- 
ward, and  descends  lower  than  is  the  case  in  the  virgin  uterus  and  in  a 
normally  placed  uterus.  The  gravid  body  of  the  uterus  has  lost  its  flat- 
tened, pyriform  shape,  is  more  balloon-shaped,  with  the  greatest  enlarge- 
ment in  the  sagittal  plane.  The  envelope,  consisting  of  decidua  and 
chorion,  is  still  fairly  uniform,  but  is  beginning  to  show  a  local  thicken- 
ing at  the  future  site  of  the  placenta,  where  the  umbilical  cord  is  in- 
serted. The  uterus  is  still  within  the  true  pelvis;  between  it  and  the 
abdominal  wall  there  is  room  for  intestines  and  omentum ;  above  the 
internal  sphincter  the  rectum,  or  rather  the  sigmoid  flexure,  is  seen 
greatly  distended ;  the  bladder  is  contracted. 


limited  to  this  structure.  In  this  portion  of  the  generative 
canal  the  cohimnar  cells  are  accordingly  shorter  and  more 
regular  in  form. 

The  uterus  requires  a  large  blood-supply,  which  is  de- 
rived from  two  sets  of  vessels  wholly  independent  of  each 
other,  whose  relations  are  well  shown  in  Fig.  31. 

Distribution  and  Relations  of  the  Arteries  of  the  Uterus 
(and  of  the  Ureters).  (Fig.  31):  Ur,  ureters;  i2,  kidneys;  Ut, 
uterus  in  ante  version,  displaced  forward  to  permit  a  view  of 
Douglas'  pouch;  the  rectum  and  peritoneum  have  been  removed; 
T,  tubes  ;  Ov,  ovaries  ;  Co,  cervix  ;  Lg.  r.,  round  ligament,  running 
from  the  insertions  of  the  tubes  into  the  fundus  along  the  bladder 
to  the  inner  portion  of  the  groin  (dissected  out  from  the  broad 
ligament).  Within  the  connective  tissue  of  the  triangular-shaped 
broad  ligaments  we  see  on  either  side  the  large  uterine  arteries, 
coming  from  the  region  of  the  hypogastric  arteries  and  the  ])elvic 
walls  and  passing  down  by  the  side  of  the  uterus  to  the  cervix, 
giving  off  branches  to  the  vagina  and  to  the  vulva.  A  small 
branch  goes  directly  to  the  cervix,  or  the  latter  may  be  supplied 
by  the  uterine  artery  itself  on  its  return  toward  the  fundus  after 
passing  below  the  internal  os.  The  branches  form  a  tortuous  net- 
work which  is  quite  characteristic  and  persists  after  impregnation 
has  occurred,  thus  enabling  the  vessels  to  accommodate  themselves 
to  the  changes  in  volume  incident  to  pregnancy.  They  run  first 
in  the  subperitoneal  tissue  (see  Fig,  14),  thence  they  radiate  into 
the  mucosa  after  forming  an  intermediate  zone  of  ramifications  in 
the  muscular  coat  for  the  supply  of  the  latter. 

Along  the  upper  border  of  the  uterus  the  uterine  arteries  form 
a  free  anastomosis  with  the  ovarian  arteries,  resulting  in  a  subperi- 


Tal).      7 


Fig.  17. 


Ansf  [\  Reicfijwld.  Miiiichen. 


DEVELOPMENT  OF  THE  OVUM.  27 

toneal  vascular  network.  These  arteries  are  branches  of  the 
aorta;  entering  the  broad  ligament  from  above  they  pass  along 
the  infuudibulopelvic  bands  from  the  ampulla  to  the  i)elvic  wall 
and  supply  principally  the  ovaries,  tubes,  and  fundus  uteri.  The 
above-mentioned  anastomosis  ascends  along  the  tubes  to  meet  the 
ovarian  artery  and  is  usually  very  well  developed. 

During  gestation  the  blood-supply  to  all  the  generative 
oro^ans  becomes  much  more  abundant,  even  the  lio;amentarv 

O  J  CD  ^ 

structures  in  the  pelvis  suffer  a  serous  infiltration.  The 
effect  of  the  labor-pains  is  to  check  the  flow  of  arterial 
blood  through  the  muscular  wall  of  the  body  of  the  uterus 
— the  lower  uterine  segment  and  cervix  are  not  affected — 
and  to  overfill  tlie  veins.  It  follows,  therefore,  that  the 
respiratory  process  in  the  placenta  is  periodically  em- 
barrassed for  a  fraction  of  a  minute  during  labor. 

The  decidua  cells  are  large  polygonal  or  oval  elements, 
sometimes  spindle-shaped  from  pressure,  and  containing 
several  nuclei  when  cell-division  is  very  active  (Fig.  15). 
They  are  formed  by  proliferation  of  the  stroma-cells  and, 
with  the  enormously  dilated  capillaries  which  branch  out 
into  veritable  sinuses,  reach  almost  to  the  epithelium,  and 
constitute  the  decidual  tissue.  The  interstitial  connective 
tissue  is  poorly  developed.  Similar  cells  have  also  been 
observed  on  the  serous  surface  of  the  broad  ligament  in 
ordinary  intra-uterine  pregnancies. 

The  chorionic  villi  penetrate  into  the  interspaces  between 
the  decidual  cells,  and  these  in  turn  send  out  processes 
which  project  into  the  intervillous  spaces.  The  villi  sub- 
serve two  purposes  :  1,  the  larger  and  more  robust,  con- 
taining connective  tissue  and  only  a  single  arterial  trunk, 
form  attachments  to  the  maternal  tissue  ;  2,  the  smaller,  or 
nutrient  villi,  with  branched  processes  containing  capillaries 
which  grow  into  the  capillary  spaces  of  the  maternal 
tissue,  serve  to  nourish  the  fetus.  There  is  no  direct  flow 
of  blood  from  mother  to  fetus.  The  intervening  wall  is 
made  up  of  the  endothelial  cells  of  the  maternal  and  fetal 
capillaries  and  the  nucleated  protoplasmic  covering  of  the 
chorionic  villi  (syncytium).  The  question  of  the  origin 
of  the  latter,  whether  embrvonal  or  maternal,  has  not  as 


28    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  18.  Retroverted  Uterus  in  the  Second  Month  of  Gestation  (after 
a  frozen  section  by  Braune). — As  the  cervix  is  forced  upward  aud  forward 
by  the  increasing  retroflexion  of  the  body,  there  is  danger  of  incarcera- 
tion under  the  curve  of  the  sacrum  as  pregnancy  progresses.  The  neck 
of  the  bladder  may  be  pressed  upon  and  distorted  to  such  a  degree  as  to 
cause  dangerous  ischuria. 


yet  been  definitely  settled;  it  is  probably  derived  from 
the  embryo  (trophoblast).  In  very  young  ova  the  syn- 
cytium is  represented  by  a  single  layer  of  cuboidal  cells 
derived  from  the  ectoderm,  but  later  it  forms  a  continuous 
band  of  protoplasm  with  nuclei  embedded  in  it  here  and 
there,  covering  the  vascular  embryonal  mucous  coimective 
tissue  of  mesodermic  origin.  The  various  embryonal  and 
maternal  tissues  also  combine  to  form  conglomerate  masses 
of  cells. 

This  close  relation  between  the  chorion  and  the  decidua, 
as  here  described,  does  not,  however,  persist  along  the 
entire  periphery.  In  the  course  of  the  first  three  months 
the  villi  in  contact  with  the  decidua  reflexa  and  the  mem- 
brane itself  cease  to  grow  and  even  undergo  marked 
atrophy,  while  at  the  place  where  the  chorion  comes  into 
direct  relation  with  the  decidua  vera  its  connection  becomes 
more  and  more  intimate  and  voluminous,  and  finally  cul- 
minates in  the  formation  of  the  placenta  serotina.  A  part 
of  the  decidua  reflexa  sometimes  retains  its  placental 
character,  and  thus  gives  rise  to  the  formation  of  the 
placenta  circnmvallata.  The  fourth  month  witnesses  the 
completion  of  the  true  placenta,  a  fiat,  cushion-like  disk 
C^cake"),  closely  adherent  to  the  anterior  or  posterior 
wall  of  the  uterus  (rarely  to  both,  by  passing  over  one 
margin  or  over  the  fundus),  from  which  the  true  fetal 
envelopes,  now  reduced  to  thin  membranes,  proceed  to 
enclose  the  fetus  and  the  umbilical  cord  w^ithin  the  amni- 
otic sac. 

The  nutrition  and  oxygenation  of  the  fetus  is  effected  by 
means  of  an  interchange  of  gases  and  the  passage,  by 
osmosis,  of  fluids  and  watery  solutions  and  even  of  formed 
elements.     [The  passage  of  oxygen  was  proven  by  Zweifel's 


Tab.     8. 


Fig.  18. 


LUh.  Anst  /.'  ReuhtwLd.  SUutxhen 


DEVELOPMENT  OF   THE   OVTM.  29 

demonstrating  the  oxyhemoglobin-band  in  the  spectrum 
of  the  blood  in  the  umbilical  vein.  Tlie  passage  of  car- 
bonic oxide,  chloroform,  ferrocyanide  of  potassium,  iodide 
of  potassium,  salicylic  acid,  iinely  divided  cinnabar,  meth- 
ylene blue,  toxins,  typhoid-fever  and  tubercle  bacilli  from 
the  maternal  blood  into  the  fetus  and  the  amniotic  fluid, 
across  the  l)oundary  l)etween  chorion  and  decidua,  and  also 
in  the  contrary  direction  from  fetus  to  mother,  is  well 
established.]  Albumin  in  considerable  quantities  is  un- 
doubtedly conveyed  to  the  fetus,  probably  by  some  com- 
plicated process,  through  the  agency  of  the  chorionic 
epithelium.  As  has  been  mentioned,  the  interchange  is 
effected  by  the  chorionic  villi ;  the  fetal  blood  is  conveyed 
to  them  by  the  two  umbilical  arteries,  and  leaves  them, 
after  having  been  purified,  in  the  single  nmbi/ical  vein. 
The  latter  passes  from  the  umbilicus  to  the  liver,  through 
the  ductus  Arantii  (venosus),  which  later  becomes  oblit- 
erated, and  the  inferior  vena  cava,  which  carries  very  little 
blood  up  to  the  ])oint  where  it  is  joined  by  the  ductus 
venosus,  to  the  right  auricle.  As  the  two  venae  cavse  are 
joined  bv  the  umbilical  vein  before  thev  enter  the  rio-ht 
auricle,  the  fetal  heart  is  supplied  only  with  mixed  blood, 
but  metabolism  is  so  slio^ht,  owino;  to  the  inactivitv  of 
most  of  the  organs  (lungs,  digestive  apparatus,  and  glands), 
that  the  nutrition  is  not  impaired.  The  active  portions 
are  chiefly  the  voluntary  muscles,  the  heart,  and  the  kidneys, 
and  this  functional  activitv,  tog^ether  Avith  the  chemical 
processes  associated  with  tissue-formation,  suflice  to  give 
the  fetus  a  temperature  of  its  own,  although  relatively  low. 
The  fetal  temperature  is  1°  F.  (J°  C.)  higher  than  the 
maternal.  During  intra-uterine  life  the  two  auricles  com- 
municate, the  valve  over  the  foramen  ovale  being  still 
open,  as  the  pulmonary  circulation  has  not  yet  been  estab- 
lished. Hence  the  blood  in  the  rio^-ht  auricle  and  in  the 
pulmonary  artery  is  carried  directly  to  the  aorta  through 
the  ductus  Botalli  (arteriosus),  which  later  becomes  oblit- 
erated. The  iliac  arteries  o^ive  off*  the  umbilical  arteries, 
which  run  in  the  umbilical  cord  and  convey  part  of  the 


30    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

blood  out  of  the  body  into  the  placenta,  ichere  the  transfer 
of  excrementitious  j^rodads  of  metaboUiim  into  the  maternal 
blood  takes  place. 

The  amniotic  fluid  (liquor  amnii)  consists  princi])ally 
of  an  exudation  from  the  maternal  blood-vessels  in  the 
chorion  and  umbilical  cord,  the  amnion  representing  a 
true  serous  membrane  ;  a  small  portion  of  the  fluid  is 
contributed  by  the  regular  functional  activity  of  the  fetal 
skin  and  kidneys.  The  fluid  contains  from  0.05  to  0.5 
per  cent,  of  albumin  and  is  swallowed  by  the  fetus  (lanugo 
hairs  are  found  in  the  meconium) ;  its  function  is  not, 
however,  to  nourish  the  fetus,  but  to  protect  it  from  ex- 
ternal injury  and  to  allow  it  free  movement. 

DIAGNOSIS  AND  ANATOMICAL  FEATURES  OF  EACH 
MONTH  OF  GESTATION. 

We  have  so  far  studied  the  development  of  the  embryo 
and  of  its  envelopes  during  the  first  month  of  gestation. 
During  this  period  the  anatomical  alterations  in  the 
maternal  organs,  especially  the  uterus,  are  so  insignificant 
that  the  diagnosis  cannot  be  made  with  any  degree  of 
probability  except  in  individuals  previously  known  to  the 
observer;  indeed,  until  the  end  of  the  fourth  month, 
when  the  parts  of  the  fetal  body  can  be  felt,  there  can  be 
no  such  thing  as  absolute  certainty.  Until  that  time  the 
degree  of  probability  will  de])end  on  the  skill  and  ex- 
perience of  the  examiner,  tlie  anatomical  characteristics 
of  the  subject  (thin  abdominal  walls,  absence  of  meteorism, 
tumors,  or  complications  in  the  form  of  inflammatory 
processes  or  cramps),  the  number  of  probable  signs  of 
pregnancy  observable,  and  the  peculiarities  of  the  indi- 
vidual. 

!^nd  of  the  First  Month. — Uterine  enlaigement 
cannot  be  made  out ;  it  amounts  to  no  more  tlian  the  en- 
largement observed  at  every  menstrual  period.  Tlie  con- 
sistency also  is  the  same  as  at  the  menstrual  period.  The 
retroversion  and  sinking  which  take  place  in  the  begin- 
ning of  the   second  month  are   not  constant  phenomena. 


DEVELOPMENT  OF  THE  OVUM.  31 

Sometimes  the  body  of  tlie  uterus  is  felt  with  remarkable 
distiuctness  close  to  tlie  anterior  vaginal  vault  and  shows 
a  marked  increase  in  its  sagittal  diameter. 

'i1ie  ovum  weighs  38  gr.  (2.5  gm.) ;  the  embryo  is  |  in. 
(0.8  cm.)  in  length. 

End  of  the  Second  Month. — The  uterus  is  the  size 
of  an  apple,  balloon-shaped  instead  of  flattened  from 
before  backward;  the  internal  os  is  circular  (in  primi- 
gravidse) ;  the  vagina  and  portio  vaginalis  are  livid  (Fig. 
38) ;  the  internal  os  begins  to  soften. 

The  ovum  is  the  size  of  a  hen's  egg.  The  embrvo  has 
assumed  a  distinctly  human  shape,  the  face  (by  closure 
of  visceral  clefts),  head,  and  extremities  being  fully 
formed.  When  this  change  takes  place  the  product  of 
conception  is  about  f  in.  (1.5  cm.)  in  length,  and  from 
this  time  on  is  termed  a  "  fetus."  By  the  end  of  the 
second  month  its  length  is  1  in.  (2.5  cm.)  and  the  head  is 
as  large  as  the  trunk.  The  formation  of  the  placenta 
serotina  begins  about  this  time,  the  decidua  reflexa  grad- 
ually undergoing  atrophy.  If  the  ovum  is  prematurely 
expelled  at  this  period  the  process  is  still  called  an 
"abortion." 

Serum  can  be  expressed  from  the  mammary  glands. 
They  are  enlarged,  turgid,  and  heavier  than  before  preg- 
nancy ;  the  swollen  acini  can  be  felt  as  thickened  cord- 
like wheals  radiating  from  the  nipple.  The  pressure  on 
the  stomach  gives  rise  to  reflex  nervous  symptoms  in  the 
form  of  dyspepsia,  and  especially  "  morning  sickness." 
In  very  neurotic  individuals  these  symptoms  become 
greatly  exaggerated,  often  to  the  extent  of  uncontrollable 
attacks  of  vomiting — hyperemesis  gravidarum. 

:End  of  the  Third  Month. — The  uterus  is  the  size 
of  a  child's  head ;  the  fundus  reaches  to  the  upper  border 
of  the  symphysis  (see  Fig.  17);  the  portio  vaginalis  is 
tilted  backward.  As  the  uterine  body  develops  much 
more  rapidly  than  the  cervix,  it  appears  like  a  round  ball 
on  a  pedicle.  The  marked  softening  of  the  loiver  uterine 
segment  (Hegar's  sign)  above  the  sacro-uterine  ligaments 


32    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  19.  Gravid  Uterus  in  the  Fourtli  Month  in  a  Primigravida. — The 

uterus  is  flabby  and  bulges  iu  various  places.  The  iutestiues  have  been 
pushed  away  from  the  abdominal  wall  and  the  fundus  projects  above 
the  symphj'sis.  A  portion  of  omentum  is  seen  interposed  between  the 
womb  and  the  abdominal  wall.  The  fetus  possesses  considerable  mobil- 
ity until  after  the  middle  of  gestation,  hence  the  position  of  the  head 
in  the  fundus ;  in  other  words,  the  breech  i)resentation  is  nothing  un- 
usual. At  this  time  the  true  placenta  is  fully  developed.  The  fetal 
membranes  cover  the  internal  os.  The  anterior  and  posterior  walls  of 
Douglas'  pouch  appear  as  two  narrow  clefts  along  the  bladder  and  rectum 
respectively  ;  posteriorly  the  subserous  lamina  is  seen  extending  deeply 
into  the  rectovaginal  septum.  The  vagina  is  narrow  and  the  rugse  are 
well  marked  ;  the  perineum  is  intact ;  the  external  os  is  closed — all 
signs  of  a  first  pregnancy. 

Fig.  20.  Gravid  Uterus  in  the  Sixth  Month  in  a  Primigravida.— The 
fundus  extends  almost  to  the  umbilicus.  Note  the  usual  attitude  of  the 
fetus  (about  one-third  natural  size),  huddled  together,  with  head  and 
extremities  flexed. 

is  best  felt  by  inserting  the  forefinger  into  the  rectum  and 
the  thumb  into  the  vagina  against  the  portio  vaginalis, 
while  the  womb  is  pressed  down  from  above  with  the 
other  hand. 

The  ovum  is  the  size  of  a  goose-egg  (Fig.  13). 

T\\Q  fetus  measures  3|  in.  (9  cm.)  and  weighs  308  gr. 
(20  gm.) ;  the  head  is  half  as  large  as  the.  trunk ;  the 
umbilical  cord  is  longer  than  the  fetus  and  begins  to  show 
twisting. 

:^nd  of  the  Fourth  Month.— The  uterus  is  as  large 
as  a  man's  head  and  palpable  above  the  symphysis;  the 
true  pelvis  is  entirely  filled.  Parts  of  the  fetal  body  can 
be  recognized  by  their  increased  resistance  (first  reliable 
sign).  It  is  possible  to  hear  the  uterine  bruit  synchronous 
with  tlie  maternal  pulse,  a  faint  breath-like  sound  ema- 
nating from  the  arteries. 

The  fetus  measures  4  to  6|- in.  (10  to  17  cm.)  and 
weighs  1  to  4^  oz.  (30  to  1 20  gm.).  The  sex  can  be  recog- 
nized by  the  external  genitalia.  If  born  "prematurely'' 
(not  "viable")  the  child  makes  respiratory  movements 
(see  Fig.  19). 

Bnd  of  the  Fifth  Month. — The  fundus  is  midway 


ai)        t 


Fig.  19. 


Tab.   10. 


Fig.  20. 


i.iih.: 


DEVELOPMENT  OF  THE  OVUM.  33 

bctireeii  the  si/)nphysis  and  the  uvthi/tcu.'^,  its  transverse  diam- 
eter coinciding  usually  with  the  rii2;lit  oblique  diameter  of 
the  pelvis  (from  the  ri(jht  sacro-iliac  junction  to  the  opposite 
iliopectineal  eminence).  In  multigravidse  the  external 
OS  is  sufficiently  relaxed  to  admit  the  examining  finger. 
Strise  and  pigmentation  appear  on  the  abdomen  (along  the 
liiiea  alba)  and  breast,  forming  in  the  latter  situation  the 
secondary  areola. 

The  fetus  measures  8  to  10  in.  (20  to  25  cm.)  and 
weighs  5  to  12J  oz.  (140  to  350  gm.).  Fetal  heart-sounds 
begin  to  be  audible  from  the  eighteenth  to  the  thirtieth 
weekj  and  about  the  same  time  fetal  7novements  can  be  both 
felt  and  heard  ;  later  they  can  also  be  seen. 

Bnd  of  the  Sixth  Month. — The  fundus  extends 
to  within  1^  to  11  in.  (3  to  4  cm.)  of  the  umbilicus ;  the 
latter  begins  to  become  shallow  from  below.  The  uterus 
gradually  assumes  a  more  oval  shape  and  thus  determines 
the  longitudinal  position  of  the  fetus.  Softening  of  the 
cervix  extends  to  a  point  above  its  middle.  The  portio 
vaginalis  is  on  a  level  with  the  spine  of  the  ischium,  but 
appears  shorter  on  account  of  the  fold  formed  by  the 
hypertrophied  vagina.  The  mother  inclines  the  upper 
part  of  the  body  slightly  backward  in  walking. 

The  fetus  measures  10^  to  13^  in.  (26  to  34  cm.)  and 
weighs  15  to  33^  oz.  (430  to  950  gm.) ;  whimpers  if  born 
prematurely.  Ujj  to  this  month  we  speak  of  "  immature 
birth  " — partus  immcdurus  (see  Fig.  20). 

:End  of  the  Seventh  Month. — The  fundus  extends 
IJ  to  1^  in.  (3  to  4  cm.)  above  the  umbilicus;  the  latter 
is  flattened. 

The  fetus  measures  14^  to  15  in.  (36  to  38  cm.)  and 
weighs  29  to  40^  oz.  (820  to  1150  gm.) ;  emits  a  wail  if 
prematurely  born  ;  the  skin  is  wrinkled  and  thickly  cov- 
ered with  hair;  the  pupillary  membrane  begins  to  dis- 
appear. As  a  rule,  a  presenting  part  of  the  child  (one 
of  the  poles  of  the  longitudinal  axis)  can  be  felt  per 
vaginam  ;  the  joarfe  of  the  fetal  body  are  easily  distin- 
guished. 


34    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  23.  Lateral  Placenta  Prsevia,  Sixth  Month  (belongiug  to  PI.  12; 
original  water-color).— We  see  the  interlacing  of  the  larger  villi  which 
serve  for  attachment  with  the  smaller,  delicate,  branching  villi  and  the 
decidua  on  the  maternal  surface.  The  lower,  bleeding  portion  corre- 
sponds to  the  part  detached  during  birth  ;  below  are  the  fetal  envelopes. 

Fig.  24.  Fetus  from  the  Sixth  Month  (two-thirds  life  size;  belonging 
to  Plate  11 ;  original  water-color),  delivered  in  incomplete  foot  presenta- 
tion.— The  skin  is  wrinkled  and  red ;  the  nails  do  not  reach  quite  to  the 
tips  of  the  fingers  ;  the  cord  is  edematous  and  gelatinous. 

Fig.  25.  Complete  Ovum  from  the  Sixth  Month  (original  drawing] : 
P/,  placenta  serotina;  Ch,  chorion;  Am,  amnion,  laid  open.  The  cord 
passes  over  the  shoulder  and  back  (one-third  life  size).  The  fetus  shows 
the  characteristic  attitude  as  described  above  (see  Fig.  20). 

l^nd  of  the  Bighth  Month. — The  fundus  is  mid- 
icay  between  the  umbilicus  and  the  epigastric  fossa.  The 
secretion  of  the  mammary  glands  makes  its  appearance. 
To  preserve  her  equilibrium  the  woman  is  forced  to  lean 
over  backward. 

The  fetus  measures  16  to  17  in.  (40  to  43  cm.)  and 
weighs  46  to  57^  oz.  (1300  to  1600  gm.) ;  can  be  kept 
alive  with  great  care.  The  arms  are  very  fat  and  red  ; 
the  skin  is  wrinkled  (see  Fig.  24). 

Bnd  of  the  Ninth  Month. — The  fundus  is  in  the 
epigastric  fossa,  about  1}  in.  (3  cm.)  below  the  ensiform 
p7^oeess.  Toward  the  end  of  the  month  the  internal  os  is 
open  in  multiparce,  the  external  os,  in  primiparce.  Greatest 
abdominal  distention. 

The  fetus  measures  18^  to  19^  in.  (46  to  48  cm.)  and 
weighs  71  to  95  oz.  (2000  to  2700  gm.).  The  head  is 
less  movable  and  has  engaged  in  the  pelvic  inlet. 

The  ovum  is  still  confined  to  the  uterine  cavity  proper  ; 
the  internal  os  now  begins  to  expand,  the  parts  having 
become  softer  and  more  distensible. 

Tenth  Month. — The  fundus  ocGU\nes  the  same  posi- 
tion as  in  the  eighth  month  and  then  usually  sinks  lower. 
Before  the  ovum  begins  to  free  itself  from  its  attachments 
the  fundus  falls  to  a  point  midway  between  the  ensiform 
process  and  the  umbilicus.  Its  position  varies,  however, 
with  the  strength  of  the  uterine  contractions ;  the  cause 


Tab.   11, 


Fig.  23. 


LLlh .  Anst  F.  Reichhold,  Miinrhdi 


/' 


^r 


\ 


^, 


Tab.  13. 


Fig.  25. 


EXA3ri2^A  TION.  35 

of  this  is  found  in  the  descent  of  the  presenting  part  into 
the  true  pelvis,  in  primiparae  as  far  as  the  pelvic  expansion. 
The  child  measures  19^  to  201-  in.  (48  to  52  cm.)  and 
weighs  6^  to  8  lb.  (3000  to  3600  gm.)  on  the  average; 
(imniottGjiaid,  53  oz.  (1500  gm.) ;  the  placenta  weighs  one- 
fifth  as  much  as  the  child  (14  to  21  to  35  oz.  -  400  to  600  to 
1000  gm.) ;  the  unibilical  cord  measures  16  in.  (50  cm.) — 
the  extremes  are  0  in  deficiency  of  the  abdominal  wall, 
and  64  in.  (200  cm.).  The  uterine  wall  becomes  progres- 
sively thinner  (segmentum  chartaceum),  so  that  the  sutwes 
and  fontanels  of  the  fetal  head  can  he  plainly  felt  through 
the  anterior  va2:inal  vault. 

To  determine  whether  a  child  is  mature  w^e  first  ascer- 
tain the  length  of  the  body,  then  the  weight,  and  the 
horizontal  (fronto-occipital)  circumference  of  the  head, 
which  is,  on  the  average,  13|-  in.  (34  cm.).  There  are,  in 
addition,  other  signs  of  maturity :  the  epidermis  is  thicker 
and  the  color  of  the  skin  pinkish  instead  of  the  deep-red 
fetal  color;  the  hair  on  the  head  is  abundant  and  several 
centimeters  long,  while  on  the  body  the  lanugo  hairs  have 
mostly  disappeared,  except  on  the  back,  the  shoulders,  and 
the  nape  of  the  neck ;  the  bones  of  the  skull  are  fairly 
firm,  tlie  fontanels  and  sutures  small ;  the  nails  project 
beyond  the  tips  of  the  fingers  ;  the  descent  of  the  testicles 
into  the  scrotum  is  usually  complete  ;  in  girls  the  nymph?e 
are  covered  by  the  labia  majora,  so  that  there  is  no  gaping 
of  the  vulva. 

The  following  thumb-rule  for  calculating  the  length  of  the  fetus 
from  the  month  of  pregnancy  is  well  known  :  from  the  first  to  the 
fifth  month  the  length  in  centimeters  is  found  by  squaring  the 
month  (thus  1.  4,  9,  16,  25  cm.);  after  that  date,  bv  multiplying 
the  month  by  5  (thus,  5  X  6  =  30,  then  35,  40,  45,  50  cm.). 


I  2.   EXAMINATION.     DIAGNOSIS  OF   PREGNANCY. 

By  inspection,  palpation,  auscidtafion,  and  mensuration 
we  ascertain  : 

1.  The  existence  or  non-existence  of   pregnancy;  2. 


36    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  26.— Fetal  Surface  of  the  Placenta  of  an  Immature  Ovum  in  the 
Sixth  Month  (original  water-color). — The  fetal  membranes  are  stripped 
back  over  the  margin  in  consequence  of  the  placenta  having  been  de- 
livered in  advance  of  the  fetus.  The  fetal  surface  is  recognized  by  the  in- 
vesting amniotic  sac,  under  which  are  seen  the  large  branching  vessels 
of  the  placenta  going  to  and  coming  from  the  umbilical  cord.  Tlie 
branches  of  the  umbilical  vein  are  distinguished  from  the  two  arteries 
by  their  lighter  color.  In  this  specimen  the  umbilical  cord  is  gelatinous 
and  edematous;  it  contained  four  vessels,  one  of  the  arteries  forming 
several  loops. 

Fig.  27.  Extrusion  of  the  Placenta  into  the  Cervical  Canal  (marginal 
placenta  prxvia ;  original  water-color  made  at  the  autopsy  of  a  woman 
Avho  died  in  the  sixth  month  of  pregnancy). — The  umbilical  cord  pro- 
jected from  the  os,  and  the  ruptured  membranes,  with  the  margin  of  the 
placenta,  were  visible  within  the  cervical  canal,  which  is  held  open  and 
expanded  from  side  to  side  to  afford  a  view  of  the  uterine  cavity.  The 
greater  part  of  the  placenta,  embracing  the  central  portion  and  upper 
margin,  still  adheres  to  the  uterine  wall.  The  spot  from  which  the  pro- 
truding portion  of  the  placenta  detached  itself  is  recognized  by  the 
clotted  blood  from  the  ruptured  uteroplacental  vessels.  Numerous  ovula 
Nahothi  were  observed  about  the  margin  of  the  external  os. 

Fig.  28.  Puerperal  Uterus  from  a  woman  who  died  of  typhoid  fever 
two  days  after  a  miscarriage  in  the  fifth  month  (original  water-color). — 
The  placental  site  is  easily  recognized,  as  is  the  boundary  between  the 
uterine  and  cervical  mucous  membrane,  which  is  clearly  indicated  by 
the  difference  in  color.  Analogous  differences  are  fouiid  in  the  uterine 
wall ;  the  upper  limit  of  a  "  lower  uterine  segment,"  belonging  to  the 
body  of  the  uterus  and  therefore  beginning  above  the  internal  os.  is 
indicated  by  a  sudden  thickening  of  the  muscularis.  Two  ovula  Nahothi 
are  seen  at  the  internal  os.  besides  numerous  similar  bodies  at  the  ex- 
ternal OS.  The  outer  portion  of  the  mucous  membrane  of  the  portio 
vaginalis,  as  well  as  that  of  the  vagina,  are  anemic.  The  latter  is  the 
seat  of  several  icteroid  cysts,  especially  near  the  vaginal  vault. 

the  month  of  pregnancy  ;  3,  the  position  of  the  fetus ; 
4,  the  life  or  death  of  the  fetus. 

By  inspection  we  determine  the  increase  in  tlie  circum- 
ference of  the  abdomen,  its  sliape — whether  conical,  pen- 
dulous, globular,  or  bul2:ing  in  the  two  hypochondriac  or 
hypogastric  regions  and  flattened  about  the  umbilicus — 
the  presence  of  recent  or  old  sfrice  gravidarum ;  pig- 
mentation of  the  median  line  of  the  abdomen  and  its 
extent ;  the  condition  of  the  breasts — their  tension,  the 
presence  of  nodes  and  cords  (determined  by  palpation) — 


Tab.  14. 


Fig.  26. 


LW. 


fieidilwld.  Munchen 


w^ 


Fig.  27 


Tab.  16. 


Fig.  28.' 


EXAMINATION.  37 

the  color  of  the  areola.  The  patient  is  asked  whether  she 
has  felt  dragging  and  stabbing  sensations  and  increased 
weight,  and  whether  milk  or  a  serons  fluid  can  be  ex- 
pressed from  the  breasts. 

In  Figs.  34-36  four  different  positions  of  the  hands  in 
palpation  are  shown.  By  the  jiist  method  (Fig.  34)  the 
height  of  the  fundus  is  determined  ;  the  second  (Fig,  34) 
enables  the  physician  to  palpate  the  back  and  extremities 
of  the  child,  and  to  detect  fetal  movements  if  any  are 
made  [back  to  the  left,  head  below  =  first  vertex  presenta- 
tion (L.  O.  A.) ;  back  to  the  right,  second  vertex  presen- 
tation (R.  O.  A.].  The  third  and  fourth  methods  are 
employed  to  locate  the  fetal  head,  whether  it  is  felt  as  a 
hard,  round  mass,  more  or  less  movable  above  the  pelvic 
inlet,  or  has  already  entered  the  pelvis,  remembering  the 
differences  between  a  primipara  and  multipara  in  this 
respect.  They  also  enable  the  examiner  to  form  an  ap- 
proximate estimate  of  the  child's  length,  which  is  often 
very  desirable,  as  it  affords  a  clue  to  the  child's  age  and 
to  the  size  of  the  head  in  proportion  to  a  contracted  pelvis. 
It  is  found  by  experience  that  the  distance  from  the  head 
to  the  coccyx,  w^hen  the  fetus  is  bent  on  itself,  is  equal  to 
half  the  length  of  the  body.  This  measurement  is  most 
easily  made  in  oblique  positions  of  the  fetus. 

The  results  of  palpation  are  confirmed  by  auscultation. 
Vie  can  hear  the  soft,  blowing  uterine  bruit,  synchronous 
with  the  maternal  pulse  and  the  fetal  heart-sounds  (120-150 
double  beats) ;  sometimes  also  the  short,  blowing  funic 
souffle,  synchronous  with  the  fetal  heart.  If  the  fetal 
heart-sounds  are  heard  the  fetus  is  unquestionably  living. 
In  the  first  vertex  presentation  the  fetal  heart-sounds  are 
heard  most  distinctly  at  a  point  midway  between  the 
umbilicus  and  the  left  anterior  superior  spine  of  the  ilium, 
emanating,  when  the  fetal  back  is  rotated  forward  by  the 
labor-pains,  not  from  the  back,  but  from  the  breast  of  the 
fetus.  Fetal  movements  are  often  heard  as  early  as  the 
fourth  month — quick,  sharp  noises  like  the  ticking  of  a 
watch — either  spontaneously  or  when  the  uterus  is  irri- 


38   PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  29.  Vertical  Sagittal  Section  of  the  Pelvis  through  the  Ligament, 
Not  Including  the  Uterus  (modified  from  Freund) :  1,  horizontal  ramus 
of  the  OS  pubis ;  11,  ascending  ramus  of  the  ischium  ;  2,  vesico-uterine  peri- 
toneal excavation  ;  3,  bladder  ;  4,  tube  in  transverse  section  ;  5,  ureter ; 
6,  peritoneal  fold  of  recto-uterine  excavation  (7) ;  9,  attachment  of  the 
uterosacral  muscular  bands  running  to  the  sacrum;  10,  rectum.  The 
vagina  and  portio  vaginalis  are  seen  through  the  opening. 

Fig.  30.  Coronal  Section  through  the  Pelvis,  showing  the  Muscles, 
Fasciae,  and  Ligamentous  Bands  in  the  Neighborhood  of  the  Genital 
Tract :  1,  peritoneum  ;  2,  superior  or  deep ;  5,  inferior  or  superficial  layer 
of  tlie  triangular  ligament  [2,  pelvis;  5,  perineum  proper];  4,  levator 
ani  muscle,  embracing  the  vagina  ;  3,  connective  tissue  above,  and  6,  below 
the  fascise  (2  and  5)  covering  the  levator  ani  muscle;  7,  obturator  fascia; 
8,  constrictor  cunni  (continuation  of  the  sphincter  ani  from  the  coccyx 
to  the  symphysis) ;  9,  obturator  internus. 

For  explanation  of  Fig.  31,  Arteries  of  the  Genital  Organs,  see  ^  1, 
p.  26. 

tated  bv  rubbing  or  kneading.     Later  the  sounds  are  more 
dull. 

In  rare  instances  singultus  and  trembling  of  the  lower 
jaw,  as  in  a  crying  child,  have  been  heard  (Meyer, 
Zurich). 

INTERNAL  EXAMINATION. 

A  vaginal  examination  during  pregnancy  subserves  a 
variety  of  purposes :  In  the  first  place,  it  is  the  only 
means  of  arriving  at  a  diagnosis  during  the  first  half  of 
gestation.  It  reveals  the  character  of  the  pelvic  cavity  and 
of  the  soft  parts,  the  presence  of  any  obstacle  which  might 
interfere  with  the  subsequent  course  and  termination  of 
pregnancy ;  and  finally,  at  the  end  of  gestation,  the  signs 
of  approaching  labor.  After  labor  has  begun,  however, 
internal  examination  is  dangerous  and  should  be  made 
only  for  very  urgent  reasons.  The  mucous  membrane  is 
soft  and  easily  injured  by  the  examining  finger,  and  the 
puerperal  uterus,  from  its  deep  situation  ^^ithin  the  abdom- 
inal cavity  and  enormous  capacity  compared  to  the  caliber 
of  the  canal  which  drains  it,  is  extremely  liable  to  infec- 
tion, being  filled  with  necrotic  material,  thrombi,  and 
blood,  especially  if  the  body-temperature  continues  high. 


Tab.   17. 


Fig.  30. 


liih.Anst  E ReichJwld-.Miuichen. 


Tab.   18. 


Fig.  31. 


EXAMTyATTO^\  39 

The  clanger  of  infection  is  therefore  greater  than  in  any 
other  kind  of  wound,  particularly  after  the  membranes 
have  ruptured.  The  busy  practitioner,  especially  the 
country  doctor  who  is  rarely  able  to  get  any  one  to  take 
his  place,  should  remember  in  such  cases  that  absolute 
surgical  cleanliness  cannot  possibly  be  achieved  ^vithin 
twenty-fours  hours  after  contamination  by  attendance  on 
a  puerperal-fever  patient,  by  the  dressing  of  an  infected 
wound,  or  by  exposure  to  the  germs  of  scarlet  fever, 
diphtheria,  etc.  In  any  case  a  full  bath  and  complete 
change  of  dress  are  imperative.  The  examiner's  hands 
and  the  woman's  vulva  must  be  disinfected  with  the 
utmost  care,  the  former  even  for  the  examination  of  a 
pregnant  woman. 

In  a  critical  case  the  question  to  be  answered  is  :  Do  the 
best  interests  of  mother  and  child  urgently  demand  a 
vaginal  examination  ? 

Seamless  rubber  gloves  which  do  not  in  the  least  inter- 
fere with  the  sense  of  touch  are  very  useful. 

The  best  mefJiod  of  disinfecting  the  skin  of  the  hands, 
vulva,  and  abdomen  consists  in  vigorous  rubbing  with  a 
brush  and  plenty  of  hot  water  and  soap  or  soda-solution, 
so  as  to  remove  all  the  fat  from  the  pores.  Sand  may 
also  be  used,  with  proper  care,  to  make  the  rubbing  more 
effective.  Any  folds  in  the  skin  are  to  be  carefully 
smoothed  out  and  rubbed  clean.  Tie  examiner  must  first 
clean  his  nails^  which  should  be  cl  )sely  trimmed,  with  a 
nail-file  and  a  soft  cloth. 

The  parts  are  then  scrubbed  with  alcohol,  if  any  is  at 
hand,  and  lastly  with  some  antiseptic  fluid,  whereupon 
the  examiner,  without  drying  his  hands  or  anointing  them 
with  a  doubtful  so-called  '"  carbolated  oil"  preparation, 
inserts  his  forefinger  into  the  vagina,  while  with  the  other 
hand  he  separates  the  lips  of  the  vulva,  which  has  pre- 
viously been  carefully  cleansed.  Before  proceeding  with 
the  vaginal  examination  the  bladder  and  rectum  must  be 
emptied,  as  otherwise  accurate  results  are  impossible. 

In  this  connection  may  be  mentioned  the  peculiar  livid 


40    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  32.  Position  of  tlie  Non-gravid.  Uterus,  wlieii  the  bladder  and 
rectum  are  moderately  di.stended.  Peritoneum  and  subdivisions  of  the 
cervix  indicated  by  red  lines  (original  drawing). — The  uterus  lies 
normally  in  a  position  of  antevei'siou  and  slight  anteflexion,  in  close  rela- 
tion with  the  bladder,  to  which  the  cervix  is  firmly  attached  in  the 
median  line  by  means  of  bands  of  connective  tissue.  The  uterus,  there- 
fore, follows  the  movements  of  the  bladder.  The  body  of  the  uterus  is 
freely  movable,  being  limited  only  by  the  intestines,  and  is  covered  with 
peritoneum  (red  line),  an  anterior  fold  extending  into  the  vesico-uterine 
excavation  as  far  as  the  internal  os,  while  a  posterior  fold,  lining  the 
recto-uterine  space  or  Douglas'  pouch,  extends  lower  and  sends  out  tw^o 
processes :  the  first,  formed  by  a  fold  of  peritoneum  at  the  level  of  the 
posterior  fornix,  contains  the  uterosacral  muscular  bands  which  run  to  the 
sacrum ;  while  the  second  is  on  a  level  with  the  external  os.  The  cervix 
is  divided  into  three  portions  :  1,  the  s^qyravaginal  portion,  extending  from 
the  internal  os  to  the  posterior  fornix ;  2,  the  intermediate  portion,  from 
that  point  to  a  line  drawn  through  the  anterior  fornix  ;  3,  the  portio 
vaginalis  proper. 

The  uterine  cavity  and  vagina  together  represent  a  curve  with  its 
concavity  looking  toward  the  symphysis.  The  vagina  is  a  muscular 
tube  with  thin  walls  and  a  larger  lumen  than  that  of  the  uterus,  the 
"portio  vaginalis"  of  which  projects  into  it  and  forms  the  deep  po.sfeWor 
and  short  anterior  fornix.  In  cross-section  the  lumen  of  the  vagina  pre- 
sents the  shape  of  a  capital  H.  The  vagina  is  held  as  in  a  sling  by  the 
levatores  ani  muscles  and  their  continuations,  the  constrictores  cunni  (see 
Figs.  9,  29,  30,  69).  The  vaginal  passage  is  closed  at  the  introitus  by  the 
hymen  or  its  remains,  the  caruncnlae  myrtiformes,  behind  which  th.Q  fossa 
navieularis  is  situated.  Externally  the  canal  is  closed  by  the  labia  and  by 
the  perineum,  with  the  frenulum  periyiei  (fourchette)  between  the  labia. 

It  is  of  practical  moment  to  remember  that  above  the  perineum  the 
rectovaginal  septum  becomes  much  narrower,  corresponding  to  the  point 
where  the  ampulla  of  the  rectum  comes  into  close  relation  with  the 
vagina. 

Fig.  33.  Position  of  Fundus  and  Portio  Vaginalis  in  Each  Month  of 
Pregnancy  (after  B.  S.  SchultzeV— The  numbers  with  periods  after  them 
indicate  the  various  positions  of  the  fundus  and  portio  vaginalis  and  the 
degree  of  abdominal  distention.  The  other  numbers  refer  to  the  ana- 
tomical designations  common  to  all  the  figures  in  the  author's  atlases 
(see  Index). 


coloring  of  the  vulva,  resembling  the  color  of  wine-yeast 
or  the  blossoin  of  the  colchicum  plant  (see  Fig.  37),  which 
may  be  observed  at  any  stage  of  pregnancy,  often  after 
the  failure  of  the  first  menstrual  flow.     During^  the  later 


05 


OS 


^^^^^^^s^^ 


C9 
CO 

6i 


CO 


EXAMINATION.  41 

months  edema  and  phlehectasla  of  the  external  pudenda 
are  often  observed. 

Tlie  examiner's  attention  should  be  directed  to  the 
following  points  :  the  state  of  the  perineum  and  pelvic 
floor,  whether  yielding  or  rigid,  or,  in  multiparse,  showing 
the  scars  of  previous  tears  ;  whether  the  introitus  is  over- 
HOisiiire  to  the  examining  finger ;  whether  there  is  any 
tendency  to  vaginismus;  the  state  of  the  vagina,  whether 
soft  and  smooth  or  rough  (in  inflammatory  conditions  and 
in  many  multiparse) ;  the  amount  of  secretion  on  the 
vaginal  walls,  and  whether  they  are  relaxed  and  thrown 
into  folds,  or  rigid  and  the  seat  of  scars  and  stenoses ;  the 
position  of  the  vaginal  portion,  whether,  as  usual,  in  the 
interspinal  line  or  directed  backward  and  upward — a  con- 
dition which  is  of  no  consequence  in  the  beginning  of 
pregnancy,  but  may  constitute  a  serious  obstacle  to  labor 
at  term  if  the  uterus  has  been  fixed  too  high  in  the  oper- 
ation of  vaginovesical  fixation — or  whether  it  is  directed 
forward  toward  the  symphysis  early  in  the  course  of 
pregnancy.  This  would  point  to  the  probable  existence 
of  retroflexion  or  bending  backward  of  the  uterus,  nar- 
mally  directed  forward  (see  Figs.  17  and  32),  under  the 
sacrum  and  into  Douglas'  pouch  (Figs.  18  and  102). 

The  following  points  are  of  especial  importance  in  con- 
nection with  pregnancy  and  labor  : 

The  Portio  Vaginalis. — Up  to  the  eighth  month  the 
vaginal  portion  of  the  cervix  in  a  prwiigravida  feels  like 
a  hard,  conical  projection  with  a  round  depression,  the 
internal  os,  at  the  summit ;  at  this  time  it  apparently 
becomes  shorter,  being  covered  by  the  hypertrophied  folds 
of  the  vagina,  and  disappears  during  the  last  few  wrecks 
in  consequence  of  the  dilatation  of  the  os.  In  maltigravidce, 
on  the  contrary,  the  lips  of  the  internal  os  persist,  being 
broader  than  the  cervix,  wliich  feels  like  a  soft  fragment 
of  tissue  lying  between  folds  of  the  vagina.  It  forms  a 
transve)^se  cleft  with  notched  edges. 

During  the  earlier  months  of  pregnancy  the  height  and 
direction  of  the  portio   vaginalis  are   not  changed ;   the 


42    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  34.  External  exaiuiuatiou  for  the  purpose  of  determining  the 
height  of  the  fundus  and  the  position  of  the  fetal  back. 

Fig.  35.  Locating  the  head  before  its  engagement  in  the  superior 
strait. 

Fig.  36.  After  the  head  has  entered  the  true  pelvis.  The  hands  are 
to  be  pressed  downward  and  inward  to  reach  the  true  pelvis. 

Fig.  37.  Vulva  of  a  Primigravida  in  the  seventh  month  (original 
water-color  from  life). — Colchicum  color  and  edema  of  the  nymphse. 

Fig.  38.  ColcMcum-colored  Fornix  of  the  Vagina  from  tlie  same  case. 
— Compare  the  color  with  the  simple  hyperemia  of  the  middle  folds  of 
the  vagina. 


direction  of  the  uterus  varies  so  much  with'in  physiological 
limits  in  different  individuals  that  it  is  impossible  to 
give  a  typical  picture.  Fig.  32  is  an  attempt  to  represent 
approximately  the  usual  position  of  the  non-gravid  uterus. 
As  soon  as  the  uterine  body  begins  to  project  above  the 
symphysis,  which  occurs  in  the  fourth  month,  it  is  inclined 
forward,  the  cervix  assuming  a  corresponding  backward 
direction  (Fig.  19).  As  the  organ  continues  to  ascend, 
the  vaginal  portion  rises  above  the  interspinal  line ;  the 
external  os  rests  on  the  j^osteri or  fornix  near  the  upper  sacral 
vertebrce  and  is  turned  toward  the  left,  the  body  of  the 
uterus  having  its  transverse  axis  in  the  right  oblique  diam- 
eter of  the  pelvis  and  being  directed  toward  the  right  The 
latter  condition  begins  in  the  fourth  month.  This  some- 
times makes  it  possible  to  palpate  the  sound  ligament  on 
the  left  side. 

The  bladder  is  drawn  upward,  so  that  obstruction  and 
dilatation  of  the  ureters  and  pelves  of  the  kidneys  some- 
times occur. 

The  OS  is  usually  directed  backward  and  downward 
(sometimes  directly  backward  if  the  anterior  wall  of  the 
uterus  sags),  or  the  cervix  may  be  bent  upon  the  body  in 
such  a  way  that  the  external  os  looks  forward  and  the 
internal  os  backward. 

In  making  a  vaginal  examination  the  physician  should, 
therefore,  ascertain" the  position,  direction,  shape,  and  con- 
sistency of  the  portio  vaginalis  ;  the  condition  and  degree 
of  dilatation  of  the  (external)  os ;  and,  finally,  the  disten- 


o 

OS 
H 


^^ 


■^4:^ 


00     ^ 


EXAMIXATIOX.  43 

tion  uf  the  cervical  canal  and  internal  os.     These 
points  are  embodied  in  the  follow  tahle  : 

Differences  observed  at  Term  between* 
A  Primi(;ravida  and  a  Multigravida. 

Vulva:  Closed.  Gapes  slightly  ;  scars. 

Vagina  :  Narrow  and  rough.  Wide,  soft,  and  smooth. 

Portia:  Soft,  relaxed  coui-.  Not  conical  ;  soft,  edematous  mass. 

External  os  :  Round  with  sharp  Open  after  fifth  month  :  edges  not 
edges:  closed  until  ninth  month.  sharply  defined,  notched;  trans- 
after  that  admits  first  phalanx.  verse  cleft. 

//  pervious,  labor  in  a  few  days.  If  cervical  canal  is  quite  patulous. 

labor  in  two  weeks. 

Internal    os :     Closed;     sometimes  Opens  during  ninth  month, 
opens  before  external  os ;  opens 
during  labor  at  the  same  time  as 
cervix,  and  before  the  external 

OS. 

Position  of  head  at  the  end  of  ges-  Until  the  beginning  of  labor  above 
tation  within  the  true  pelvis.  the  superior  strait,  or  but  slightly 

engaged  in  the  true  pelvis,  so  that 
it  is  freely  movable. 

During  the  first  three  months  the  size,  shape,  consistency, 
and  position  of  the  uterine  body  can  be  ascertained  by 
means  of  bimanual  examination,  one  hand  on  the  abdomen, 
the  fino^ers  of  the  other  in  the  vaofiua  or  rectum.  If  the 
uterus  cannot  be  felt  above  the  anterior  fornix,  and  the 
vaginal  portion  is  in  contact  with  the  pubic  symphy.sis, 
there  is  retroflexion,  which  may,  and  usually  does,  correct 
itself  spontaneously  as  pregnancy  progresses.  It  is  better 
practice,  however,  to  replace  a  retroflexed  uterus,  because 
the  procedure  incidentally  reveals  the  presence  of  any 
inflammatory  adhesions  in  Douglas'  pouch. 

A  characteristic  sign  in  the  early  stages  of  pregnancy  is 
the  doughy  softness  in  the  region  of  the  internal  os — Hegar's 
.-ign.  It  forms  a  conspicuous  area  of  relaxation,  separating 
the  hard,  globular  uterine  body,  distended  l)y  the  ovum, 
from  the  cervix,  which  does  not  lose  its  hardness  until 
later. 

In  the  bimanual  examination  the  physician  should  search 
for  other  abnormalities,  such  as  tumors  of  the  orenitalia  or 
their  adnexa,  or  of  neighboring  organs,  malformations  of 
the  uterus  or  vagina  (double  vagina,  septa,  etc.),  inflam- 


44    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 

Fig.  39.  Usual  Position  of  Portio  Vaginalis,  directed  obliquely  back- 
ward and  downward,  in  a  multipara  at  term. — The  external  os  is  open  ; 
the  head  has  not  yet  entered  the  true  pelvis ;  second  vertex  presentation 
(back  on  the  right  side,  E.  O.  A.).  Digital  method  of  measuring  diagonal 
conjugate  (from  the  lower  border  of  the  sj'mphysis  to  the  promontory  of 
the  sacrum).     (Original  drawing.) 

Fig.  40.  The  Head  has  Entered  the  True  Pelvis  (at  term )  and  is  Push- 
ing the  Anterior  Lower  Uterine  Segment  downward;  the  Portio  Vagi- 
nalis is  directed  Upward  and  Backward. — Primigravida,  first  vertex 
presentation  (L.  O.  A.).  It  is  often  difficult  in  these  cases  to  reach  the  os; 
the  finger  should  be  bent  at  the  distal  joint  (original  drawing). 

Fig.  41.  Anterovertical  Position  of  the  Portio  Vaginalis  in  a  primi- 
gravida at  term. — The  head  is  engaged  in  the  superior  strait ;  cervical 
canal  still  closed  (original  drawing). 

matory  processes,  abscesses,  extravasations  in  Douglas' 
pouch,  etc.  The  uterine  artery  can  usually  be  felt  pul- 
sating through  the  vaginal  wall.  Examination  of  the 
portio  vaginalis  and  of  the  walls  of  the  vagina  with  a 
speculum  is  useful  only  in  the  beginning  of  pregnancy  ; 
it  shows  the  wine-veast  or  colchicum  color  of  the  parts 
(see  Figs.  37  and  38). 

From  the  beginning  of  the  fifth  month  the  parts  of  the 
fetal  body  can  be  distinctly  felt,  and  fetal  movements  as  well 
as  the  fetal  heart-sounds,  lW-150  double  beats  per  minute, 
can  be  heard.  In  this  month  the  dilatation  of  the  external 
OS  begins  in  multiparse.  A  more  accurate  calculation  of 
the  duration  of  pregnancy  now  becomes  possible. 

At  the  end  of  pregnancy  our  calculations  as  to  the  oyiset 
of  labor  are  based  on  the  state  of  the  cervical  canal,  the 
position  of  the  head  relative  to  the  superior  strait,  the  size 
of  the  child,  and  the  level  of  the  fundus. 

The  general  ride  for  calculating  the  termination  of  preg- 
nancy is  to  count  back  three  months  from  the  date  of  the 
last  menstruation  and  add  from  seven  to  ten  days.  The 
'^average  duration  "  of  pregnancy  is  tw^o  hundred  and 
sixty-five  to  two  hundred  and  eighty  days ;  but  there  are 
well-authenticated  cases  in  which  tlie  duration  was  three 
hundred  days  and  over,  a  circumstance  which  is  sometimes 
important  in  a  medicolegal  point  of  view.  Occasionally 
an  ovum  discharged  during  the  preceding  period  is  fertil- 


CM 
(M 


(73 


:§^ 


<; 


DIAGNOSIS  OF  PREGNANCY.  45 

ized,  but  this  is  rare  ;  the  impregnated  ovum  usually  dates 
from  the  time  of  the  first  menstruation  missed.  The 
great  vitality  of  the  spermatozoa  makes  conception  possible 
even  when  there  is  an  interval  of  a  week  or  more  between 
menstruation  and  coitus.  Lastly,  it  must  be  borne  in 
mind  that  ovulation  may  take  place  in  the  intervals 
between  the  menstrual  periods. 

To  recapitulate,  the  (.Jlagnostic  signs  of  pregnancy  are  : 

(a)  Probable  signs,  derived  from  the  mother  and  ema- 
nating from  her  generative  organs,  as :  livid  color  of 
nympha? ;  relaxation  of  the  vaginal  portion  of  the  cervix 
and  characteristic  softening  of  the  internal  os ;  increased 
secretion  in  the  cervical  canal,  which  becomes  dilated  in 
the  fifth  month  in  multiparse ;  globular  enlargement  of 
the  uterine  body  in  the  sagittal  diameter;  enlargement  of 
the  mammary  glands  due  to  beginning  secretion  (serous 
from  the  second  month  on)  and  swelling  of  glandular 
acini,  which  radiate  in  thickened  cords  from  the  nipple  to 
the  periphery  ;  enlargement  of  the  abdomen,  stride  (reddish 
if  recent,  in  nmltiparse  alternating  with  whitish  scars,  due 
to  stretching  of  the  elastic  tissues  and  parallel  displacement 
of  subcutaneous  fibers),  pigmentation  in  the  median  line 
of  the  abdomen  ;  cessation  of  the  menses ;  uterine  bruit. 

The  greater  number  of  these  signs  may  be  observed  in 
inflammatory  conditions,  circulatory  disturbances,  and 
with  tumors  of  the  generative  organs  ;  for  instance,  milk 
secretion  of  the  mammae. 

[b)  Positive  signs  belonging  to  the  child,  as  :  palpation 
of  fetal  parts  and  fetal  movements  ;  auscultation  of  the 
latter,  of  the  fetal  heart-sounds  (120-150),  and  of  the 
synchronous  funic  souffle. 

The  most  typical  of  the  unreliable  signs  are  :  morning 
sickness ;  vertigo  ;  irregular  stools  (constipation  and  diar- 
rhea) ;  frequent  micturition  ;  edema  and  varicose  conditions 
of  the  lower  extremities ;  various  forms  of  neuralgia. 
These  symj^toms  are  more  pronounced  in  neuropathic 
subjects,  and  especially  in  twin  and  extra-uterine  preg- 
nancies. Pigmentation  of  the  face,  hollow  eyes  and  cheeks, 
and  psychic  alterations  are  also  to  be  mentioned. 


46    PHYSIOLOGY  AND  DIAGNOSIS  OF  PREGNANCY. 


In  addition  to  these  general  phenomena  we  find  corre- 
sponding changes  in  all  the  organs  of  the  body  durimr 
pregnancy.  For  the  purpose  of  comparison  the  following 
table  has  been  compiled,  to  shoAV  the  changes  incident  to 
the  pregnant  state  and  the  retrograde  changes  observed  in 
the  puerperium  : 


Alterations  in  the  Non-sexu 
and  in  the 
Pregnancy. 

Bladder :  Displaced  upward,  com- 
pressed ;  increased  desire  to  urinate 
or  frequent  micturition  ;  ureters 
and  pelvis  of  kidney  dilated,  de- 
generation of  renal  epithelium. 

Urine:  Quantity  increased,  spe- 
cific gravity  lower,  contains  albu- 
min, and  sometimes  sugar  (the 
kidney  of  pregnancy ;  the  urine  must 
always  be  examined) ;  kidneys,  liver, 
spleen,  and  thyroid  gland  hypertro- 
phied. 

Heart:  Left  ventricle  probably 
hypertrophied  (the  pulse  is  more 
rapid,  and  a  difference  is  observed 
when  the  patient  changes  from  a 
recumbent  to  a  standing  posture, 
which  is  possible  only  after  com- 
pensation has  been  established). 

Blood:  Hydremia  and  leukocyto- 
sis; during  the  first  half  of  preg- 
nancy the  number  of  red  blood- 
corpuscles  is  diminished  (lience  the 
hydremia) ;  hemoglobin  increased. 


AL  Organs  during  Pregnancy 
Puerperium. 

Puerperium. 

Urine:  Quantity  diminished  on 
the  first  and  second  day  ;  minimum 
is  reached  on  the  fourth  day,  after 
which  it  begins  to  increase  ;  con- 
tains lactose,  acetone  ;  percentage 
of  nitrogen  in  proportion  to  amount 
of  milk  secretion  (greatest,  there- 
fore, from  the  third  to  the  fifth 
day);  peptonuria  (due  to  breaking 
down  of  uterine  muscle ;  also  found 
in  the  lochia;  absent  after  amputa- 
tion of  uterus) ;  pepsin. 

Pulse  1  .•  Often  falls  to  40-60  imme- 
diately after  delivery  and  is  soft; 
this  does  not  by  any  means  occur 
in  all  cases,  as  was  formerly  sup- 
posed, perhaps  not  even  in  the  ma- 
jority ;  idiosyncrasy  plays  the  most 
important  role. 

Leukocytosis  disappears ;  number 
of  red  blood-corpuscles  unchanged, 
hemoglobin  diminishes  in  the  first 
few  days.  Toward  the  end  of  the 
lochia  serosa  (seventh  day)  both  red 
and  white  blood-cells  are  increased. 
At  this  time  many  microcytes  and 
small,  highlj'  refractive  elements 
are  seen. 

1  Various  reasons  are  given  for  the  remarkable  diminution  in  the  pulse- 
rate  so  often  observed  after  childbirth,  such  as  alteration  in  the  blood- 
pressure,  the  mental  and  physical  rest  in  the  horizontal  position  and 
collapse  of  the  abdomen  (hence  stasis  in  the  abdominal  veins,  less  blood 
in  the  heart  and  lungs,  fall  of  blood-pressure),  the  slowing  of  the  respi- 
ration, ^ew^raZ  retardation  of  all  the  functions — pulse-rate  diminished  during 
inspiration  (sucking  action  of  lungs  in  the  pleural  cavity ;  the  lung 
capacity  rises  on  the  third  to  the  fifth  day).  Other  theories,  as  absorp- 
tion of  the  fatty  uterine  muscle,  disturbances  of  innervation,  less  demand 
on  the  heart,  etc.,  appear  to  be  refuted  by  the  facts  that  the  same  reduc- 
tion in  the  pulse-rate  is  observed  after  abortions,  or  as  early  as  thi'ee 
hours  postpartum,  and  that  the  urine  is  increased  in  amount.  The 
reduction  in  the  pulse-rate  is  rarely  observed  in  neuropathic  women. 


DIAGNOSIS  OF  PREGNANCY.  47 

Lungs:   Widely   separated    from  Vital  lung  capacity  increased  on 

each  other,  diaphragm  higli.  thorax      the  third  daj'^. 
expanded  laterally  and  sagittal  di- 
ameter diminished.    Vital  capacity 
unchanged. 

JiDier  table  of  sic  nil :  Osteophytes. 

Gums  hypertrophied. 

St//i ;' Increased  secretion,  chlo- 
asmata. 

Plilebectasix  in  the  lower  extrem- 
ities. 

Intestine:  Much  constipation,  at  Physiologic  constipation  till  the 

first  diarrhea;  hemorrhoids.  third  or  fourth  day  (size  of  stools 

increases  when  meat-diet  is  taken). 

The  following  points  are  important  in  the  differential 
diagnosis  of  pregnancy  from  other  conditions  : 

1.  Menstruation  persists  and  is,  as  a  rule,  increased  in 
metritis,  myoma  of  the  uterus,  and  ovarian  cysts.  There  is 
no  change  in  the  patienfs  condition.  If  there  is  a  tumor 
and  menstruation  ceases,  the  neoplasm  is  usually  found  to 
be  attached  to  the  uterus  by  a  distinct  pedicle,  consisting 
of  the  tube  and  ovarian  ligament,  and  the  question  of 
ectopic  gestation  must  be  considered. 

2.  In  heniatonietra  menstruation  is  absent  from  the  start. 
On  examination  with  the  speculum  and  uterine  sound  the 
cervix  is  found  to  be  occluded,  the  menstrual  blood  being 
collected  above  the  cervix  within  the  uterine  body  or  in 
the  tubes.  (Great  care  must  be  observed  in  the  combined 
examination.) 

3.  Para-  and  perimetritis  give  rise  to  febrile  attacks, 
which  should  be  inquired  for  ;  the  examination  \t:  attended 
with  great  pain. 

4.  In  retroflexion  there  is  a  characteristic  anterior  dis- 
placement of  the  vaginal  ])ortion  of  the  cervix  and  the 
anterior  lip  of  the  os  is  much  attenuated.  The  portio 
vaginalis  itself  is  hard  ;  the  uterine  body  cannot  be  felt 
above  the  anterior  fornix.  The  differential  diagnosis  is 
often  very  difficult,  as  a  retroflexed  uterus  is  apt  to  become 
excessively  swollen  and  soft.  If  the  pain  continues  severe 
and  menstruation  is  persistently  absent  (with  retention  of 
urine),  the  possibility  of  pregnancy  in  a  retroflexed  uterus 
should  be  considered. 


48    PHYSIOLOGY  AND  DT A  GNOSIS  OF  PREGNANCY. 

5.  In  retro-uterine  hernatocele  a  HuctLiatiiig  tumor  is  felt 
in  Douglas'  pouch,  arching  the  posterior  fornix  downward 
and  merging  directly  into  the  uterine  body  without  the 
interposition  of  a  pedicle.  The  pain  comes  on  suddenly, 
since  this  form  of  intraperitoneal  hemorrhage  is  almost 
exclusively  caused  hy  the  rupture  of  a  gravid  tube — in 
short,  a  tubal  pregnancy. 

6.  The  physician  should  always  bear  in  mind  how  often 
such  conditions  as  a  distended  bladder,  obesity,  showing 
itself  in  greatly  thickened  abdominal  walls,  meteorism,  and 
constipcdion  have  led  to  an  erroneous  diagnosis  of  preg- 
nancy, especially  when  the  woman  herself  is  firmly  con- 
vinced that  she  is  pregnant,  menstruation  is  absent,  and 
the  breasts  become  enlarged  and  even  begin  to  secrete. 
In  neurotic  individuals  such  imaginary  conditions  quite 
frequently  occur  (spurious  pregnancy,  grossesse  nerveuse). 

7.  Particular  attention  should  be  given  to  the  diagnosis 
of  a  dead  fetus  in  utero,  especially  during  the  period  when 
the  fetal  parts  cannot  be  recognized  by  palpation.  Fetal 
heart-sounds  and  movements  are  absent;  from  the  history 
it  is  learned  that  probable  and  unreliable  signs  of  preg- 
nancy were  present,  but  that  the  typical  enlargement  of 
the  abdomen  has  ceased  and  the  swelling  in  the  breasts  has 
subsided.  The  woman  complains  of  frequent  chills  (ab- 
sorption). The  dead  fetus  is  often  retained  within  the 
uterus  several  months,  undergoing  maceration,  mummi- 
fication, or  total  absorption. 

So  far  we  have  been  engaged  in  discussing  the  internal 
examination  of  the  soft  parts,  but  the  examination  of  the 
pelvis  itself  is  never  to  be  neglected  in  any  case  of  preg- 
nancy. At  least  it  should  be  ascertained  that  there  is  no 
contraction,  that  no  marked  asymmetry  exists,  and  that 
the  walls  are  free  from  exostoses  or  osteomata.  In  general 
terms  it  may  be  said  that  the  jx'lvic  cavity  should  be  large 
enough  to  accommodate  a  man's  fist  comfortably,  or,  to  be 
more  accurate,  if  an  internal  examination  is  made  with 
the  index  and  middle  fingers,  the  promontory  should  be 
almost  or  quite  beyond  the  reach  of  the  middle  finger  (see 


DIAGNOSIS  OF  THE  NORMAL  FEMALE  PELVIS.   49 

Fig.  39).  It  is  then  certain  that  the  usual  form  of  con- 
traction, in  the  sagittal  diameter  called  '^conjugata/'  is  not 
present.  We  then  satisfy  ourselves  by  palpating  the  lateral 
and  anterior  walls  of  the  pelvis  that  there  is  no  lateral  dis- 
placement or  inward  projection  of  the  pelvic  bones,  noting 
whether  there  is  abnormal  tenderness.  Finally,  we  must 
not  forget  to  estimate  roughly  with  the  fingers  the  dis- 
tances between  the  spines  and  the  tuberosities  of  the 
ischium,  corresponding  to  the  pelvic  outlet.  A  cursory 
survey  of  the  entire  skeleton,  including  the  angle  of  the 
false  pelvis,  will  suffice  to  detect  any  signs  of  rachitis. 

A  detailed  examination  of  the  pelvis  by  means  of 
measurement  necessitates  an  accurate  knowledge  of  the 
different  varieties  of  deformed  pelves. 


CHAPTER   11. 


ANATOMY,    DEVELOPMENT,   AND   EXAMINATION 
OF   THE   PELVIS. 

§  3.  DIAGNOSIS  OF  THE  NORMAL  FEMALE  PELVIS. 

The  genital  tract  is  contained  in  the  pelvis  and  sup- 
ported by  it ;  in  the  later  months  of  pregnancy  it  rests 
partly  upon  the  pelvis.  The  characteristic  shape  of  the 
female  pelvis  is  determined  partly  by  the  erect  attitude  of 
the  individual,  partly  by  the  pregnant  and  parturient 
genital  apparatus.  The  male  pelvis  presents  only  those 
qualities  which  depend  on  the  erect  attitude,  the  female 
pelvis  is,  therefore,  more  specialized,  although  not  so 
robust ;  it  may  be  roughly  described  as  more  roomy  and 
more  expanded  laterally. 

^y  ins2:)eetion  and  j^cdpcttion  we  determine  whether  the 
shape  is  symmetrical  (for  instance,  obliquely  distorted  or 
with  one  iliac  bone  higher  than  the  other) ;  the  woman  is 
examined  in  a  standing  posture  or  lying  on  her  back. 
We  satisfy  ourselves  that  there  is  no  kyphosis,  lordosis, 

4 


50       ANATOMY  AND  EXAMINATION  OF  PELVIS. 

Fig.  42.  Measurement  of   tlie  Transverse  Diameter  of  the  Outlet 

(after  Breisky)  :  10,  tuberosities  of  the  ischia;  7a,  anus;  20,  introitus 
vaginae. 

Fig.  44.  Accurate  Measurement  of  tlie  True  Conjugate  with  the  Pel- 
vimeter (after  Skutsch). — With  this  instrument,  which  can  be  easily 
bent  in  any  direction,  the  examiner  first  measures  the  distance  between 
the  promontory  and  the  external  surface  of  the  symphysis  (continuous 
lines),  and  then  tlie  thickness  of  the  latter  (broken  lines),  introducing 
one  branch  of  the  instrument  through  the  vagina,  the  bladder  having 
been  previously  evacuated.  The  difierence  between  these  two  measure- 
ments is  the  true  conjugate. 

Fig.  45.  Measurement  of  the  External  Conjugate  (diameter  of  Bau- 
delocque)  with  the  Baudelocque-Martin  Pelvimeter  (Fig.  43;  original 
drawing). — Measure  from  the  upper  edge  of  the  symphysis,  compressing 
the  overlying  fat,  to  the  spinous  process  of  the  last  lumbar  vertebra  in 
the  deepest  part  of  the  rhomboid  fossa. 

Fig.  56.  Accurate  Measurement  of  the  Transverse  Diameter  of  the 
Inlet  with  the  Same  Instrument. — First  ascertain  the  distance  from  the 
iliopectineal  line  (extremities  of  transverse  diameter)  to  the  outer  sur- 
face (trochanter)  of  the  opposite  thigh  (continuous  .lines),  and  subtract 
the  distance  from  trochanter  to  iliopectineal  line  on  the  same  side 
(broken  lines) ;  the  result  represents  the  transverse  diameter  of  the  pel- 
vic inlet. 


or  scoliosis  of  the  vertebral  column.  Attention  should 
be  given  to  the  general  build  of  the  patient,  whether  she 
is  rachitic  or  dwarfish  in  stature;  to  the  shape  of  the 
head,  whether  square  with  high  frontal  eminences ;  and 
to  the  shape  of  the  chest  (chicken-breast)  and  legs  (bow- 
legs). If  the  distance  between  the  two  anterior  superior 
spines  of  the  ilium  can  be  spanned  with  the  outstretched 
hand  the  pelvis  is  contracted.  This  distance,  from  thumb 
to  little  finger  on  an  average  man's  hand,  is  about  9J  in. 
(2:3  cm.). 

The  following  external  measurements  are  taken  with  the 
Baudelocque-Martin  pelvimeter  (see  Figs.  43  and  45) : 

1.  The  distance  betiveen  the  anterior  superior  spines, 
lOJ  in.  (26  cm.)  in  the  living  subject;  9^  in.  (24  cm.)  in 
the  skeleton.  Place  the  knobs  of  the  pelvimeter  firmly 
against  the  spines. 

2.  The  distance  between  the  crests  of  the  iliac  bones, 
11 J  in.  (28  cm.)  in  the  living  subject;  lOf  in.  (27  cm.) 


Tab.  23. 


Fig.  42. 


Fig.  43. 


Fig.  44. 


Fig.  45 


Lith.Anst  E  RetcfOwld,  MCuiciien 


DIAGNOSIS  OF  THE  NORMAL  FEMALE  PELVIS.    51 

in  the  skeleton.     Measure  between  the  two  points  most 
widely  separated. 

3.  The  (Uainder  of  Baudelocque  (external  conjugate), 
7 J  in.  (19.5  cm.)  in  the  living  subject;  7J  in.  (18  cm.)  in 
the  skeleton.  This  diameter  corresponds  to  the  distance 
between  the  spinous  process  of  the  fifth  lumbar  vertebra 
and  the  upper  edge  of  the  symphysis  pubis.^ 

4.  The  transverse  diameter  of  the  pelvic  outlet^  Z\  to  4  in. 
(8  to  10.8  cm.)  in  the  living  subject;  3^  to  3f  in.  (8  to 
9.2  cm.)  in  the  skeleton.  Place  the  woman  in  the  lithot- 
omv  position  and  measure  between  the  inner  edges  of  the 
tuberosities-  (see  Fig.  42). 

And  in  deformed  pelves  :^ 

5.  The  external  oblique  diameter,  9  in.  (22.5  cm.)  in 
the  living  subject ;  8^  in.  (21.5  cm.)  in  the  skeleton  ;  from 
posterior  superior  spine  to  anterior  superior  spine  of  the 
opposite  side.     Both  diameters  should  be  measured. 

6.  The  anteroposterior  diameter  of  the  pelvic  outlet  (con- 
jugate of  pelvic  contraction),  4  to  5^  in.  (10  to  14  cm.) 
in  the  living  subject;  4^  in.  (11.5  cm.)  in  the  skeleton. 
Sims'  position  ;  from  the  lower  extremity  of  the  sacrum 
to  the  lower  border  of  the  symphysis. 

7.  The  intertrochanteric  distance,  in  the  living  subject, 
12^  in.  (31  cm.).  Place  the  knobs  against  the  outermost 
points  of  the  trochanters,  the  legs  being  extended. 

8.  The  distance  between  the  posterior  supei'ior  spines,  in 
the  living  subject,  3|-  in.  (9.8  cm.).  Place  the  knobs  in 
the  dimples  on  either  side  of  the  spine. 

9.  The  circumference  of  the  pelvis,  in  the  living  subject, 
36  in.  (90  cm.).  Measure  witK  the  tape  from  the  sym- 
physis to  the  middle  of  the  sacrum  along  the  lower  border 
of  the  ilium  and  back  on  the  other  side. 

1  The  spinous  process  of  the  last  lumbar  vertebra  is  the  second  process 
felt  above  the  line  joining  the  two  dimples  which  mark  the  position  of 
the  two  posterior  superior  spines,  at  the  deepest  point  of  the  rhomboid 
fossa. 

2  Klien's  instrument  is  a  useful  one  for  this  measurement. 

3  See,  also,  under  generally,  obliquely,  and  transversely  contracted  and 
compressed  pelres. 


52       ANAT03IY  AND  EXAMINATION  OF  PELVIS. 

Fig.  46.  Palpation  of  the  Spines  of  the  IscMum  after  the  head  has 
descended  (original  drawing). — The  head  is  completely  engaged  in  the 
true  pelvis  and  "immovable."  The  cervical  canal  is  "obliterated," 
being  completely  filled  by  the  head  ;  the  external  os  is  about  as  large  as 
a  half-dollar.  The  sagittal  sutui'e  coincides  with  the  right  oblique 
diameter;  the  largest  diameter  of  the  head  is  below  the  inlet  in  the 
plane  of  greatest  expansion.  (The  red  lines  show"  the  contour  of  the 
pelvis;  for  numerals,  see  Index). 

Fig.  47.  Sagittal  Section  througli  a  Fetal  Pelvis. — The  red  lines  rep- 
resent the  soft  parts. 

Fig.  48.  Sagittal  Section  througli  the  Fully  Dilated  Birth- canal 
Represented  Within  the  Pelvis ;  the  soft  parts  are  stretched  to  their 
utmost  (for  instance,  14,  perineum).  The  resistance  offered  by  the  bony 
and  soft  parts  is  indicated  by  arrows.  The  direction  taken  by  the 
advancing  head  as  it  emerges  is  also  shown  by  a  curved  line  of  arrows 
(the  curve  of  Carus).  The  coccyx  (3)  and  the  jjerineum  are  forced  back- 
imrd.  The  axis  of  the  pelvic  canal  passes  through  the  centers  of  the 
conjugates  of  all  the  pelvic  planes.  Its  curve  is  determined  by  the  con- 
cavity of  the  sacrum  and  coccyx  on  the  one  hand,  and  by  the  greater  height 
of  the  posterior  wall  of  tbe  pelvis  compared  to  the  anterior,  i.  e.,  the 
symphysis  (1) ;  40  and  41,  tuberosacral  and  ischiosacral  ligaments. 

With  the  exception  of  the  fourth,  these  measurements 
have  only  a  relative  value.  For  instance,  the  distance 
between  the  spines  should  be  less  than  that  between  the 
crests.     In  the  rachitic  pelvis  tliis  relation  is  reversed. 

By  subtraction  w^e  estimate  approximately  the  following 
more  important  internal  measurements  ; 

The  distance  between  the  crests  minus  about  5f  to  6  in. 
(14.1  to  15  cm.  [4f  to  5  in.  =  11.5  to  12.5  cm.  in  flat 
pelves])  is  equal  to  the  transverse  diameter  of  the  inlet, 
5i  in.  (13.5  cm.). 

The  oblique  diameter  minus  about  4  in.  (10  cm.) — the 
right  is  normally  somewhat  longer  than  the  left^ — equals 
the  oblique  diameter  of  the  inlet,  5  in.  (12.5  cm.). 

The  external   conjugate  minus  3^  to  3f  (8  to  9  cm.) 

1  The  normal  pelvis  presents  a  slight  scoliosis  toward  the  left  side, 
hence  the  right  oblique  diameter,  from  the  right  sacro-iliac  articulation 
to  the  pubic  spine  of  the  opposite  side,  somewhat  exceeds  in  length  the 
left  oblique  diameter  at  tbe  inlet;  tlie  right  half  of  the  pelvis  is  some- 
what flattened  and  tbe  sacrocotyloid  distance  on  that  side  is  shorter 
than  on  the  other.  The  external  diameters  usually  bear  the  same  rela- 
tions to  each  other  as  the  internal,  especially  if  the  difference  is  great. 


DIAGNOSIS  OF  THE  NORMAL  FEMALE  PELVIS.   53 

equals  the  true  conjur/afey  4.V  in.  (11  cm.).  If  tlio  external 
conjno:ate  is  6^  in.  (16  cm.)  or  less  the  pelvis  is  certainly 
contracted  ;  if  7^  in.  (18  cm.)  it  is  contracted  in  half  the 
cases. 

The  followinir  hiternal  measurements  are  actually  made  : 
The  d'uujoudl  conjugate,^  5  in.  (12.5  cm.)  minus  |  in. 
(1.5  cm.) — in  flat  rachitic  pelves,  f  to  1  in.  (2  to  2.5  cm.)  — 
the  conjugata  vera,  4|-  in.  (11  cm.),  from  the  lower  border 
of  the  symphysis  to  the  promontory.  The  index  and 
middle  lingers  are  inserted  into  the  vagina,  with  the 
thumb  placed  against  the  symphysis  and  the  other  two 
fingers  folded  into  the  palm,  and  the  promontory  is  felt 
with  the  middle  finger  (Fig.  39).  The  examining  finger 
is  then  swept  along  the  curve  of  the  iliopectineal  line  to 
detect  any  points  of  abnormal  resistance,  asymmetry,  or 
exostoses,  especially  at  the  so-called  synchondroses  or 
points  where  the  several  layers  of  fetal  bone  become 
fused. 

The  measurements  of  the  inlet  can  also  be  accurately 
determined  with  the  aid  of  instruments,  after  Skutsch 
(see  Figs.  44  and  b^). 

Skiagraphy  naturally  suggests  itself  as  an  aid  to  pelvimetry, 
particularly  as  only  a  few  minutes'  exposure  is  necessary  for  the 
purpose.  In  fact,  it  is  possible  not  only  to  obtain  a  clear  picture 
of  the  pelvis  but  also  to  measure  certain  distances.  Radioscopy 
alone  (with  the  screen)  gives  a  more  or  less  satisfactory  picture  in 
the  non-pregnant  woman  ;  it  is  best  to  use  the  plate  in  the  dark 
chamber.  The  woman  is  placed  on  her  back  and  the  plate  pushed 
well  under  the  buttocks,  so  that  it  projects  2  in,  (5  cm.)  beyond 
the  vulva.     These  skiagraphs  are  particularly  useful  in  the  diag- 

^  The  diagonal  conjugate  is  the  distance  between  the  lower  border  of 
the  symphysis  and  the  promontory.  From  it  we  calculate  the  true  con- 
jugate, which  does  not,  however,  lie  exactly  in  the  plane  of  the  pelvic 
inlet,  as  the  latter  cuts  the  sacrum  below  the  promontory.  If,  when  the 
woman  is  examined  in  the  dorsal  position  (Figs.  39,  55),  the  promontory  is 
bej'ond  the  reach  of  the  middle  finger,  the  diofjonal  coujufjnte  exceeds  4§  in. 
(11.5  cm.) ;  if  the  buttocks  are  raised,  as  in  Fig.  HI,  it  is  5  to  51  in.  (12.25 
to  13  cm.).  A  similar  increase  in  the  length  of  the  conjueate  occurs  in 
Watcher  s  posture  (Fig.  62),  which  is,  therefore,  a  useful  position  in  labor 
when  the  pelvis  is  contracted.  On  the  other  hand,  the  conjugate  of  the 
outlet  is  shortened  by  the  Walcher  posture  and  increased  by  the  lithotomy 
position. 


54       ANATOMY  AND  EXAMINATION  OF  PELVIS. 

nosis  and  mensuration  of  asymmetrical  pelves ;  they  furnish  the 
following  measurements  :  1,  The  distance  between  the  posterior 
superior  spines ;  2,  the  width  of  the  sacrum  ;  3,  the  distance  from 
the  lumbosacral  crest  of  the  spine  to  the  posterior  superior  spine 
of  the  ilium  ;  4,  the  distance  from  the  middle  of  the  promontory 
to  the  sacro-iliac  articulation. 

The  tratisverse  diameter  of  the  outlet  is  obtained  from  a  photo- 
graph taken  in  the  sitting  posture,  deducting  f  in.  (2  cm.)  for  the 
thickness  of  the  soft  parts.  Finally,  one  can  ascertain  the  curve 
of  the  pubic  arch  and  the  transverse  diameter  of  the  pelvic  inlet. 

Dimensions  of  the  Individual  Portions  of  the 
Normal  Female  Pelvis. — The  false  pelvis  is  formed 
by  the  iliac  bones  and  the  last  two  lumbar  vertebrae ;  its 
dimensions  correspond  to  the  distances  between  the  various 
points  of  the  iliac  bones^  which  have  just  been  given.  It 
supports  the  intestines  and,  after  the  fourth  month  of  ges- 
tation, the  body  of  the  uterus. 

The  true  pelvis  begins  at  the  pelvic  inlet,  in  the  plane 
which  passes  through  the  promontory  and  the  upper  edge 
of  the  symphysis,  encircled  by  the  iliopectineal  line.  The 
posterior  wall  of  the  true  pelvis  is  formed  by  the  sacrum, 
the  lateral  and  anterior  walls  by  the  ischium  and  pubis. 
The  ascending  and  descending  rami  of  these  bones  enclose 
the  obturator  foramen  and,  with  the  iliac  bone,  form  the  ace- 
tabulum for  the  reception  of  the  head  of  the  femur.  In 
girls  between  twelve  and  fourteen  the  triradiate  figure  of  the 
synchondrosis  can  be  seen  on  the  floor  of  the  acetabulum. 
The  open  space  between  the  sacrum  and  ilium  (ineisura 
ischiadica)  is  traversed  by  two  strong  bands,  the  tubero- 
sacral  and  ischiosacral  ligaments.  The  sacro-iliac  joint 
(formed  by  the  "auricular^'  cartilages)  and  the  symphysis 
pubis  are  strengthened  by  capsules  and  ligaments.  The 
so-called  anterior  wall  of  the  pelvis  is  very  narrow,  being 
formed  by  the  two  pubic  bones,  the  rami  of  which,  with 
the  rami  of  the  ischium,  form  the  pul)ic  arch. 

The  cavity  of  the  true  pelvis  presents  several  planes  of 
varying  dimensions  (see  Figs.  48,  55,  70-72).  The  plane 
of  the  inlet ;  the  plane  of  greatest  pelvic  expansion  between 
the  middle  of  the  body  of  the  third  sacral  vertebra  and 


DIAGNOSIS  OF  THE  NORMAL  FEMALE  PELVIS.   55 

the  middle  of  the  symphysis,  its  lateral  boundaries  being 
the  great  sacroseiatic  notch  and  the  wall  of  the  acetabulum  ; 
the  plane  of  least  pelvic  expansion,  passing  through  the 
riixid  sacrococcygeal  articulation,  the  ischial  spines,  and 
the  lower  border  of  the  symphysis  (the  intcrspindl  line  in 
this  plane  corresponds  with  the  smallest  diameter  of  the 
pelvis) ;  and  the  plane  of  the  outlet,  which  is  concave,  as 
its  boundaries  occupy  different  levels  :  the  movable  tip 
of  the  coccyx  and  the  lower  border  of  the  symphysis 
and,  on  a  lower  level,  the  tubera  ischii. 

Xot  only  does  the  same  diameter  vary  in  the  different 
planes,  but  the  relations  between  the  various  diameters 
also  vary,  so  that  each  plane  has  a  different  shape.  Con- 
siderable difiPerences  are  noted  not  only  in  different  races 
and  peoples  but  also  in  individuals.  The  oblique  diame- 
ters are  the  most  constant  of  all  the  diameters  at  the  inlet, 
while  general  contractions,  and  especially  a  shortening  of 
the  true  conjugate,  are  for  some  unknown  reason  observed 
most  frequently  in  certain  planes  (rachitis). 

Con JUG ATA  Yeea. 

{between    promontory 
and  upper  border  of 
symphysis.^ 
(  tbird   sacral   vertebra 
In  the  plane  of  greatest  expansion.  5  in.  (l'2.5em.)  <     to  middle  of  symphy- 

(    sis. 

(  sacrococcygeal  articu- 
In  the  plane  of  least  expansion,  4f  in.  ill.5  cm.)  -,    lation  to  lower  border 

(    of  symphysis. 
.,  ,,  .1   .    ,  .     «•?  .      /-inj-    n         \  f  tip  of  coccTx  to  lower 

Attheoutlet.  4to4jin.  (10tol2cm.)     .....    border  of  symphysis. 

Transverse  Diameter. 

[  greatest   distance   be- 

At  the  inlet.  o\  in.  1 13.5  cm.  i tween     iliopectineal 

(    lines. 

T     .V       1  /.  .     .  .        4^  •      ,n         .  I  distance  between  ace- 

In  the  plane  of  greatest  expansion.  4$  in.  (12  cm.  i       tahnla 

T     .,        1  ^  1      X  •        .  •        -i,-.  '  distance   between    is- 

In  the  plane  of  least  expansion.  4  in.  1 10  cm.i    .        rhial  snines 

..  .,          4.1  J.    49  •      /1-1         \  '  distance   between  tu- 

At  the  outlet.  4f  in.  (11cm.) bera  i.^chii. 

1  The  obstetric  conjugate  of  the  inlet  is  situated  i  in.  (i  cm.)  lower. 


56       ANATOMY  AND  EXAMINATION  OF  PELVIS. 

Fig.  49.  Normal  Female  Pelvis  in  erect  posture  (front  view  ;  original 
drawing  from  a  specimen  in  the  Munich  Gynecological  Clinic). 

Fig.  50.  Generally  Equally  Contracted  Pelvis,  practically  a  miniature 
reproduction  of  the  normal  pelvis,  with,  however,  certain  infantile  char- 
acteristics. The  iliac  bones  are  relatively  and  absolutely  smaller,  the 
promontory  is  less  prominent  (original  drawing  from  a  specimen  in  the 
Munich  Gynecological  Clinic). 

Fig.  51.  Greatly  Contracted  Funnel- shaped  Pelvis  ("  Liegbecken," 
decubital  pelvis)  Approaching  the  Fetal  Form  (see  '0^  4  and  19).— The 
sacrum  is  straight,  the  iliac  bones  are  small  and  fiat,  the  pelvic  inlet 
is  more  circular  than  normal,  and  there  is  marked  contraction  at  the 
outlet,  the  result  of  years  spent  in  bed,  from  infancy  until  death,  which 
occurred  about  the  age  of  puberty.  The  weight  of  the  trunk,  the 
counter-pressure  of  the  thighs,  and  the  action  of  the  muscles  are 
eliminated  (original  drawing  from  a  specimen  in  the  Munich  Gyneco- 
logical Clinic). 


Oblique  Diametek. 

(  sacro-iliac articulation 

At  the  inlet,  5  in.  (12.5  cm.) <    to  iliopubic  tubercle 

(,   of  opposite  side. 

{great  sacrosci  ati  c  n  otch 
to  obturator  sulcus  of 
opposite  side. 
T     X 1,      1           ^  1      J-               -1  r  extensible,       because 

In  the  plane  of  least  expansion  t bounded      by     liga- 

^t  *^^ '^"t'^^*  '  1    ments. 

The  importance  of  examining  the  pelvis  before  giving 
a  prognosis  of  the  probable  conrse  of  labor  has  just  been 
emphasized. 

^  4.  SHAPE   AND   INCLINATION   OF  THE   ADULT 
FEMALE  PELVIS  AND  ITS  DEVELOPMENT. 

The  normal  adult  female  pelvis  as  contrasted  with  the 
male  has  a  large  transverse  diameter.  Three  factors  enter 
into  its  development  from  the  fetal  ])elvis  : 

The  formation  of  the  promontory  ; 

Lateral  expansion  ; 

Disappearance  of  the  funnel  shape. 

A  knowledge  of  the  structure  of  the  fetal  pelvis  and 
its  subsequent  development  up  to  the  age  of  puberty  is 


Tab.  25. 


Fig   51 


Lith.  Ansi  E Retchhald,  Miimhm,. 


siiArr:  of  Anri/r  female  fflvjs.  57 

necessary  tor  the  comprclicnsion  of  the  various  foi'ins  of 
pelvic  deformity. 

The  sluipe  and  inclination  of  the  pelvis  are  determined  by  the 
action  of  three  forces:  the  weight  of  the  trunk,  the  coinUrr-jjrcsHure 
of  the  thi(/hfi,  and  the  resi.<<ta?ice  ofiered  by  the  xiiiiijjhij.^ix,  and  by 
three  developmental  factors : 

1.  A  forward  movement  analogous  to  the  anteflexion  of  the  uterus. 
The  promontory  falls  forward  as  a  result  of  the  superincumbent 
weight  of  the  trunk  (cf  Fiir.  53  with  Figs.  54  and  55);  the 
sacrum  is  beni  and  pushed  uj)ward  and  backward  ;  the  ilia  and 
the  upper  part  of  the  sacrum  rotate  forward ;  tiie  loicer  border  of 
the  symphysis,  which  in  the  fetus  projects  forward,  moves  in  the 
opposite  direction,  backward.^ 

2.  The  first  developmental  moxement  is  almost  compensated  for 
by  a  second,  which  forces  the  portion  of  the  pelvis  in  front  of  the 
great  sciatic  notch  upward,  the  most  anterior  portions  (toward  the 
symphysis)  being  most  affected.  This  is  the  result  partly  of  the 
pressure  of  the  thighs  (cf  Figs.  52,  53,  57  wdth  the  ''decubital 
pelvis,"  Fig.  51),  partly  of  the  inherent  hereditary  tendency  of  the 
right  horizontal  ramus  of  the  pubis  to  undergo  rapid  growth,  and 
thus  produce  a  lateral  expansion  of  the  pelvis,  to  which  among 
other  factors  the  sacro-iliac  ligaments  also  contribute  (No.  32  in 
Fig.  57)  by  drawing  the  iliac  bones  backward.  Up  to  the  fifth 
year  this  movement  plays  an  important  role,  owing  to  the  softness 
of  the  bones,  the  transverfte  diameter  being  affected  more  than  the 
anteroposterior. 

3.  x\  slight  scoliosis  of  the  pelvis  to  the  left  occurs  as  a  result 
of  hypertrophy  of  the  right  horizontal  ramus  of  the  pubis  and 
adjoining  portion  of  the  acetabulum,  and  of  the  left  ala  of  the 
sacrum  and  iliopectineal  line  ;  the  svmphvsis  is  displaced  to  the 
left. 

As  a  result  of  the  two  movements  described  under  1 

^  This  movement,  the  result  of  the  characteristic  wedge-shaped  growth 
of  the  hambar  and  sacral  vertebrje  (and  the  consequent  formation  of  the 
promontory),  is  directly  dependent  on  heredity  and  the  erect  posture  in 
walking.  The  tendency  begins  in  the  embryonal  and  fetal  period,  but 
its  completion  is  brought  about  in  each  individual  by  the  exercise  of  his 
functions.  The  angle  of  the  femur  with  the  long  axis  of  the  vertebral 
column  in  the  fetus,  in  the  new-born,  and  in  tlie  adult  is  found  to  be 
respectively  1.30,  1G2,  and  19.")  degrees,  showing  that  there  is  a  gradual 
movement  backward  on  the  part  of  fennir.  pelvis,  and  sacrum.  This 
movement  is  effected  by  the  extensor  muscles  of  the  vertebral  column, 
the  sacrospinal  muscle  (see  Figs.  .53  and  54) ;  note  the  military  hyper- 
extension  of  the  pelvis  in  Fig.  54.  The  influence  of  muscular  action  on 
the  shape  of  the  pelvis  and  of  the  bones  in  general  has  been  proven 
experimentally  by  dividing  the  muscles  in  young  animals  and  observing 
the  subsequent  abnormal  development  of  the  bones  (Kehrer). 


58       ANATOMY  AND  EXAMINATION  OF  PELVIS. 

Fig.  52.  Female  Fetal  Pelvis  in  erect  posture  (front  view  ;  original 
drawing  from  author's  specimen). — The  sacrum  is  almost  straight;  the 
promontory  projects  very  little.  The  uncolored  surfaces  represent  the 
cartilaginous  portions  that  have  not  yet  undergone  ossification.  The 
pubic  arch  forms  a  right  angle. 

Fig.  53.  Sagittal  Section  through  a  Fetal  Pelvis,  showing  the  Angle 
of  the  Femur  with  the  Spinal  Axis.— The  peculiarities  of  a  fetal  pelvis 
described  in  the  foregoing  figure  appear  even  more  plainly  in  this  one. 

Fig.  54.  The  Same  in  the  Adult.— The  promontory  has  fallen  forward  ; 
the  sacrum  is  pushed  upward  and  backward  ;  the  position  of  the  sym- 
physis is  more  posterior  than  in  the  fetus. 

and  2,  the  pelvic  angle  ^  in  the  adult  woman  measures  from 
50  to  55  degrees,  in  an  easy,  erect  posture  with  the  legs 
parallel  to  each  other.  The  angle  varies  from  40  degrees 
in  a  stiff,  military  attitude,  or  the  attitude  of  a  pregnant 
woman,  to  100  degrees  in  the  recumbent  posture  with  the 
trunk  bent  over  in  front  and  the  knees  drawn  up  ("  ano- 
dorsal  position  ^^  [see  Fig.  61],  i.  e.,  lithotomy  position). 
On  account  of  this  wide  variation  the  measurement  has 
no  obstetrical  value,  although  it  is  interesting  from  an 
anthropological  point  of  view ;  but  the  'pradical  bearing 
is  of  the  greatest  value  as  determining  the  best  positions 
for  the  various  obstetrical  and  gynecological  processes  and 
operations.     We  shall  return  to  this  later. 

The  changes  in  the  pelvis  incident  to  its  development  are  given 
in  the  following  comparative  table,  and  serve  to  explain  deformi- 
ties due  to  arrested  development  or  to  pathological  conditions  in 
infancj^ : 

Fetal  Pelvis.  Adult  Female  Pelvis. 

Difference  between  sexes  distinct 
in  the  fourth  month  (Fehling). 

8m.all    transverse    diameter,    from  Large  transverse  diameter. 

the  third  month  on. 

Conjugate   vera:   transverse  di- 
ameter =  100 :  105-108 =100:122. 

Promontory  very  hifih,  lumbosa-  Promontary  projects /oeiDard!  and 

cral  convexity  very  slight.  into   the  pelvis,   lumbosacral   con- 

vexity angular. 

1  By  pelvic  angle  is  meant  the  angle  formed  by  the  plane  of  the  pelvic 
inlet,  or  the  true  conjugate,  with  the  horizon  when  the  body  is  in  the 
erect  posture ;  in  this  posture  the  symphysis  is  lower  than  the  promon- 
tory. The  height  of  the  posterior  wall  of  the  pelvis  (promontory  to  tip 
of  coccyx)  is  5i  in.  (13  cm.);  that  of  the  anterior  wall  (symphysis)  is  If 
in.  (4  cm.). 


Tab.  26. 


LWv.Anst  E  R£icfLlwUi,Mmicheri. 


SHAPE  OF  ADULT  FEMALE  PELVIS. 


59 


Angle  of  pelvic  inlet  =  75  to  80 
degrees  

Sacrum  and  coccyx  almost  verti- 
cal and  straight. 

Sacrum  tlat  from  side  to  side  ; 
bodies  of  vertebrae  larger  than  alee 
and  cuboidal  (posterior and  anterior 
borders  at  the  same  level). 

Sacrum  relatively  narrow. 

Pubic  arch  =  70-90  degrees.    .    . 

All  the  diameters  of  the  true 
pelvis  are  relatively  much  smaller 
than  in  the  adult  female  pelvis 
(corresponding,  therefore,  to  the 
"funnel-shaped"  contracted  pel- 
vis). 

Iliac  bones  narrow,  steep,  and 
flat. 

Angle  of  iliac  bone  v^ith  ilio- 
pectineal  line  =  155  degrees  .  .    .    . 

Tubera  ischii  at  outlet  nearer  to- 
gether than  spines. 


=  55  to  60  degrees.^ 

Sacrum  and  coccyx  vertical  and 
concave. ■■^ 

Sacrum  concave  from  side  to  side  ; 
bodies  of  vertebrae  just  as  large  as 
the  ake ;  anterior  and  posterior 
borders  wedge-shaped. 

Sacrum  relativelv  very  broad. 
95-100  degrees. 

All  the  diameters  of  the  true 
pelvis  considerably  larger  com- 
pared with  the  true  conjugate, 
especially  the  transverse  and  ob- 
lique diameters. 


Iliac  bones  broad, 
ally,  and  concave. 


inclined  later- 


=  125  degrees. 

The  distance  between  the  spines 
of  the  ischium  represents  abso- 
lutely the  shortest  pelvic  diameter. 


^  If  by  means  of  Chrobak's  apparatus  the  mean  inclination  of  the  ex- 
ternal (Baudelocque)  diameter  is  found  to  be  46.6  degrees,  and  that  of 
the  true  conjugate  51.8  degrees,  the  mean  difference  will  be  in  a  normal 
pelvis  5.18  degrees,  in  a  "large"  pelvis  8.8  degrees,  in  the  simple  flat 
pelvis  still  greater — 12.9  degrees,  while  in  the  rachitic  flat  pelvis  it  may 
be  less  or  even  negative.  Again,  it  is  greater  in  rachitic  non-contracted 
pelves  (15-23  degrees),  and  in  generally  contracted  pelves  12  degrees 
(Savor). 

2  The  most  dorsally  situated  portion  corresponds  to  the  articulation 
with  the  auricular  surface  of  the  ilium  and  to  the  insertion  of  the  com- 
mon extensor  muscle  of  the  trunk;  the  sacral  curve  is,  therefore,  to  be 
considered  as  the  resultant  of  these  two  factors  :  the  weight  of  the  trunk 
and  the  traction  of  the  extensor  muscles  of  the  trunk  in  the  erect  post- 
ure. The  coccyx  is  drawn  forward  by  the  coccygeal  muscle  and  the  levator 
ani,  that  is,  toward  their  points  of  insertion :  the  spines  of  the  ischium 
and  the  symphysis.  The  ligaments  connecting  the  spines  and  tubera 
ischii  with  the  sacrum  have  the  same  effect.  According  to  my  investiga- 
tions the  upper  portion  of  the  sacrum  is  rotated  backward  through  70 
degrees,  the  posterior  arch  of  the  great  sciatic  notch  the  same,  but  the 
anterior  arch  rotates  only  through  40  degrees,  that  is,  the  anterior  por- 
tion of  the  true  pelvis  is  not  rotated  backward  as  much  as  the  posterior 
portion.  As  a  result,  we  have  the  developmental  movement  described 
above  under  Xo.  2  :  the  tilting  upward  in  front  and  the  diminished  incli- 
nation of  the  pelvic  inlet  in  the  adult.  In  the  same  way  the  symphysis 
rotates  backward  only  50  degrees,  and  as  the  rotation  of  the  .sacrum  is  70 
degrees,  the  symphysis  is  raised  a  distance  proportional  to  the  remaining 
20  degrees  (see  position  of  symphysis  in  movement  No.  1,  this  section). 


60       ANATOMY  AND  EXAMINATION  OF  PELVIS. 

Fig.  55.  Sagittal  Section  of  a  Normal  Adult  Female  Pelvis  in  the 
Erect  Posture  (original  drawing  from  a  specimen  in  the  Munich  Gyne- 
cological Clinic). — To  show  the  inclination  of  the  pelvic  inlet,  that  is, 
the  relative  positions  of  promontory  and  symphysis. 

Fig.  56.  Measurement  of  the  Transverse  Diameter  of  the  Inlet,  after 
Skutsch  (see  explanation  of  Fig.  44). 

Fig.  57.  Effect  of  the  Pressure  of  the  Thighs  and  the  Traction  of  the 
Iliosacral  Ligaments  (Weight  of  the  Trunk)  on  the  Shape  of  the  Pelvis  : 
32,  iliosacral  ligaments. 

Fig.  58.  Pelvic  Angle  in  the  Ordinary  Dorsal  Position. 

Fig.  59.  Pelvic  Angle  when  the  Trunk  is  Raised. 

Fig.  60.  Pelvic  Angle  with  the  Legs  Drawn  Up  (lithotomy  position). 

Fig.  61.  Pelvic  Angle  when  the  Lumbosacral  Region  is  Raised  and 
the  Thigh  Drawn  Up. 

Fig.  62.  Pelvic  Angle  in  Walcher's  Position  with  Legs  Hanging  Down. 

Fig.  63.  Pelvic  Angle  in  Semilateral  Knee-elbow  or  Sims'  Position. 
(Original  drawings.) 

VARIATIONS  IN  THE  PELVIC  INCLINATION  AND 
THEIR  PRACTICAL  VALUE. 

In  the  flat  dorsal  position  with  the  sacrum  slightly  sup- 
ported the  pelvic  inclination  is  25  degrees  (Fig.  58,  "  incli- 
nation of  decnbital  pelvis  ").  In  the  dorsal  position  with 
the  trunh  slightly  raised  the  inclination  is  20  degrees  (Fig. 
59) ;  in  Sims'  position  with  "  hollow  back,"  also  20  degrees 
(Fig.  59) ;  in  tlie  lithotomy  position  (Fig.  60),  30  degrees ; 
in  anodorsal  decubitus  (buttocks  raised,  loins  touching  the 
couch,  legs  drawn  up,  Fig.  61),  60  degrees. 

The  greatest  inclination  is  obtained  in  the  Walcher 
position  (the  woman  lies  flat  on  her  back  and  lets  her  legs 
hang  down  over  the  edge  of  the  couch),  with  a  decubital 
pelvic  angle  of  10  degrees  (Fig.  62),  or  by  the  knee-elbow 
position  (j^ositiou  d  la  vache),  with  an  angle  of  15  degrees 
(Fig.  63),  which  equals  that  of  Sims'  position  (semilateral 
knee-elbow  position). 

"  AYalcher's  position  "  takes  its  name  from  its  author, 
who  recommended  its  use  in  the  flat  (?*.  e.,  anteroposteriorly 
contracted)  pelvis,  because  it  increases  the  length  of  the 
conjugate  from  -J-  to  f  in.  (^  to  H  cm.). 

If  the  head  is  arrested  by  the  symphysis  and  fails  to 
engage  in  the  true  pelvis,  or  if  it  is  desired  to  make  an 


vO 


ft; 


Tab.  28. 


Fig.  58. 


Fig.  59. 


Fig.  60. 


Lith.Ansl  E  ReicfUiold,  Mimchen . 


Tab.  29. 


Fig.  61 


Fig.  63 


lith.Arhsi  EReicfihold.Miinrhm. 


SHAPE   OF  ADULT  FEMALE  PELVIS.  61 

internal  examination  for  the  purpose  of  measuring  the 
diatronal  conjiifrate,  the  decubital  angle  may  be  increased 
bv  mi:«ing  the  buttocks  and  depres-ing  the  spinal  column 
(Figs.  60  and  61).  By  this  procedure  the  promontory  is 
brouo:ht  nearer  the  examining  finger  and  the  conjugate  is  in- 
creased, being  made  as  nearly  as  possible  vertical  to  the 
long  axis  of  die  fetus  and  uterus.  The  latter  falls  back- 
ward and  occupies  a  plane  perpendicular  to  that  of  the 
inlet.  The  \vhole  length  of  the  spinal  column,  especially 
the  lumbar  region.,  must  l)e  firmly  pressed  against  the 
couch.  All  these  positinns  tend  to  relax  tlie  muscles  con- 
nectincr  the  pelvis  and  femora,  and  thereby  also  dilate  the 
birth-canal.  Thus,  when  the  head  engages  in  the  superior 
strait,  AValcher's  position  is  very  useful  in  difficult  labors, 
On  the  other  hand,  when  the  head  is  approaching  the  out- 
let, that  is,  during  its  passage  through  the  vulva  and  over 
the  perineum,  the  smaller  the  pelvic  angle  in  the  dorsal 
position  the  nearer  will  Ije  the  head  to  the  symphysis  and 
the  smaller,  therefore,  the  danger  of  a  perineal  tear  (Tigs. 

51,  60). 

The  lithotornij  position  is  tu  he  u.-ed  in  nperatiuns  on 
the  vulva  (perineal  tears)  or  on  the  anterior  fnrnix -.  on 
the  vaginal  portion  of  the  cervix  (suturing  lacerations) 
after  a  speculum  has  been  introduced  (legs  flexed  on 
abdomen);  and  when  the  head  engages  in  the  outlet. 

AValcher's  position  is  sometimes  useful  in  celiotomies, 
to  facilitate  the  drawing  of  a  tumor  or  of  the  gravid 
uterus  into  the  operative^  field.  There  are  certain  modi- 
fications of  this  position  which  also  tend  to  throw  the 
intestines  against  the  diaphragm  and  bring  the  pelvic 
viscera  into  view,  as  Trendelenburg's  and  Yeit's  positions 
(the  trunk  is  placed  low,  either  the  knees  or  the  pelvis 
forming  the  highest  part  of  the  body).  A  knowledge  of 
the  influence  of  these  positions  may  be  of  great  impor- 
tance in  the  performance  of  Cesarean  section,  Porro's 
amputation  of  the  uterus,  and  other  obstetrical  operations 
on  the  abdomen,  labor  complicated  bv  ^m  obstructing 
tumor,  ectopic  gestation,  and  rupture  of  the  uterus. 


62  NORMAL  LABOR. 

CHAPTER   III. 

NORMAL    LABOR. 

The  Forces  of  Expulsion  and  Resistance  Concerned  in  the  Presenta- 
tion and  Expulsion  of'  the  Fetus.  Uterine  Muscle,  Vagina. 
Muscles  of  the  Perineum,  Pelvic  Planes. 

I  5.  THE  UTERINE  MUSCLE  AND  ITS  FUNCTIONS  DUR= 
INQ  PREGNANCY  AND  LABOR. 

The  virgin  uterus  is  pear-shaped  (Figs.  30-'i2,  64,  77) ; 
it  measures  2f  to  3^  in.  (7  to  8  cm.)  in  length,  1^  in. 
(3  cm.)  in  its  greatest  transverse  diameter,  and  weighs 
1  to  1\  oz.  (30  to  40  gm.) ;  its  walls  are  thicker  than  they 
are  during  the  greater  part  of  pregnancy. 

Immediately  after  delivery  a  well-contracted,  anteflexed 
uterus  is  somewhat  more  globular,  but  ^i\\\  flattened  from 
before  backward  on  its  posterior  surface ;  its  length  is  6| 
to  7^  in.  (16  to  18  cm.) ;  the  thickness  at  the  fundus  J  to 
\\  in.  (2  to  4  cm.);  the  length  of  the  cavity  as  determined 
with  a  sound  is  about  6  in.  (15  cm.) ;  the  weight  is  26 J  to 
351  oz.  (750  to  1000  gm.). 

During  pregnancy  the  organ,  therefore,  increases  in 
absolute  weight,  in  circumference,  and  in  the  thickness 
of  its  walls  (see  Figs.  27,  28,  76),  the  greater  part  of  the 
increase  being  added  to  the  muscular  layer.  The  latter 
fulfils  i\NO  functions  during  this  period  :  the  support  of 
the  ovum,  which  is  embedded  in  the  uterine  mucosa,  now 
transformed  into  the  decidua,  and  draws  sustenance  from 
its  abundant  capillary  and  lacunar  vascular  system  ;  and 
the  presentation  of  the  mature  fetus.  In  addition,  the 
uterine  muscle  effects  the  expulsion  of  the  ovum.  The 
growth  of  the  uterus  is  at  first  an  active  process,  affecting 
both  the  length  and  the  thickness  of  the  muscle-fibers, 
and  does  not  depend  on  the  pressure  of  the  developing 
ovum  ;  for  the  ovum  is  smaller  than  the  uterine  cavity 
during  the  first  weeks  of  pregnancy,  and  the  uterine 
enlargement  takes  place  also  in  ecto2:)ic  gestation. 


THE   UTEBINE  MUSCLE  AND  ITS  FUSCTIONS.     63 

The  size  and  shape  of  the  uterus  are  determined  by  the 
extent  of  the  muscular  increase  and  tlie  growtli  of  the 
individual  fibers.  This  is  seen  most  clearly  in  the  first 
and  second  months,  when  the  uterine  cavity  is  larger  than 
the  ovum  (Figs.  17,  18),  showing  that  the  uterus  has  an 
independent  growth  exceeding  that  of  the  ovum.  The 
decidua  refiexa  and  decidua  vera  do  not  begin  to  coalesce 
before  the  fourth  month. 

The  cervix  in  the  virginal  as  w^ell  as  in  the  gravid 
uterus  is  poorly  supplied  with  muscular  fibers ;  its  func- 
tion is  a  passive  one,  at  first  to  close  the  birth-canal  and 
later  to  allow  the  ovum  to  escape.  Even  in  the  virgin 
state  its  chief  difference  lies  in  the  structure  of  its  mucous 
membrane,  which  is,  in  fact,  incapable  of  producing  a 
decidua.  In  rare  cases  the  upper  segment  of  the  cervical 
canal  undergoes  exceptional  development  and  assists  in 
supporting  the  ovum,  either  owing  to  an  intrinsic  ten- 
dency to  the  formation  of  more  robust  muscular  fibers 
and  unusual  elasticity  of  the  uterine  body,  or  because  of 
a  relaxed  and  softened  state  of  the  internal  os,  as,  for 
instance,  in  inflammatory  conditions  (Bayer,  Klistner,  v. 
HerflP).  This  is  almost  always  the  case  in  primiparse 
toward  the  end  of  gestation.  Its  occurrence  depends 
rather  on  accidental  processes  and  functional  variations 
than  on  a  true  hyperplasia  of  the  tissue-elements. 

The  muscularis  of  the  cervix  is  composed  of  a  relatively  thin 
layer  of  obliquely  circular  fibers  (Fio:.  65),  traversed  by  numer- 
ous strands  of  connective  tissue  with  some  elastic  fibers,  the  latter 
being  most  numerous  at  the  external  os. 

The  muscularis  of  the  body  and  fundus  consists  of  two  layers 
which  can  be  traced  into  the  tubes,  the  vagina,  and  the  various 
ligaments,  where  they  insert  (like  the  outer  layer)  below  the  serous 
surface  and  radiate  into  the  substance  of  the  ligaments.  The 
outer  layer  (Fig.  64)  is  composed  of  oblique  longitudinal  fibers 
which  interlace  as  they  pass  from  one  half  of  the  uterus  to  the 
other;  some  of  the  fibers  run  more  deeply  and  merge  with  the 
in7ier  layer.  In  postpartum  contractions  of  the  uterus  the  bundles 
composing  this  outer  layer  can  be  distinctly  felt,  and  they  can 
also  be  demonstrated  in  the  prepared  specimen.  The  muscularis 
of  the  fundus  proper  is  formed  by  the  inner  layer;  it  consists  of 
two  robust  masses  of  circular  fibers  on  either  side  of  the  organ, 


64  NORMAL   LABOR. 

Fig.  64.  Superficial  Layers  of  the  Uterine  Muscle  (after  Deville,  from 

the  atlas  of  Leuoir,   See,  aud  Tarnier) :   T,  tube;  P,   ijortio  vaginalis; 
Lg.L,  broad  ligament. 

Fig.  65.  Deep  Layers  of  the  Uterine  Muscle  {Ibid.). 

Fig.  66.  Arrangement  of  the  Muscle-fibers  (after  C.  Euge). 

Fig.  67,  a  and  b.  Decidua  Vera  Complete  after  expulsion  (see  ^  12). 


the  continuation  partly  of  the  inner  circular  and  partly  of  the 
outer  longitudinal  iibers  of  the  tubes.  They  are  thus  grouped 
about  two  central  foci  which  correspond  to  the  points  of  origin 
of  the  oviducts  (Fig.  65).  Evidences  of  the  formation  of  the 
uterus  by  the  union  of  Miiller's  ducts  are  plainly  recognized  in 
this  region.     The  inner  layer  is  the  first  to  develop. 

It  is  not  always  easy  to  distinguish  these  two  layers.  Formerly 
three  layers  were  described ;  the  middle  portion,  being  particularly 
well  supplied  with  blood-vessels,  was  called  the  stratum  vascuhsum 
(Fig.  14). 

In  order  to  get  a  clear  understanding  of  the  function  of  the 
uterine  muscle  we  divide  the  fibers  into  two  groups  : 

The  principal  fibers  run  lengthwise  from  the  peritoneum  to  the 
mucous  membrane,  traversing  the  intermediate  tissues  of  the 
uterine  wall  more  or  less  obliquely  and  in  a  downward  direction. 
These  fibers  are  crossed  by  the  connecting  fibers  which  run  vertically, 
the  whole  forming  a  succession  of  rhomboid  masses  covered  as  with 
roofing-tiles  by  the  superincumbent  outer  layer  (C.  Ruge's  "mus- 
cle-rhomboids," Fig.  66).  The  cross-fibers  are  derived  from  the 
round  ligaments,  the  ovariopelvic  folds,  the  broad  ligaments,  the 
sacro-,  recto*,  and  vesico-uterine  ligaments,  and  from  the  muscular 
fibers  accompanying  the  blood-vessels. 

This  irregular  picture  (Fig.  14)  of  muscle-fibers  crossing  each 
other  in  every  direction  is  seen  in  the  non-pregnant  as  w^ell  as  in 
the  puerperal  uterus.     It  is  the  result  of  the  uterine  contractions. 

The  gravid  uterus,  on  the  other  hand — except  in  the  first  few 
months — appears  much  distended  in  every  direction  and  its  walls 
are  correspondingly  tldn.  This  is  because  the  non-contracting 
fibers  are  greatly  increased  in  length  ^  without  being  increased  in 
number  (Sanger).  They  are  now  all  arranged  in  parallel  longitu- 
dinal rows,  separated  by  loose  areolar  connective  tissue.  Hence 
the  softening  first  of  the  uterus  and  later  of  the  cervix  that  is  so 
distinctly  felt. 

The  longitudinal  distention  of  the  organ  is  due  to  the  growth 
of  the  principal  fibers,  its  increased  circumference  to  that  of  the 
connecting  fibers. 

In  expanding  peripherally  the  uterus  mechanically  displaces 
the  loose  connective  tissue  of  the  broad  ligaments  like  an  intra- 

1  The  length  is  increased  tenfold,  the  width  fivefold. 


Tab.  SO. 


THE   VTEmyE  MUSCLE  AND  ITS  FUNCTIONS.    65 

ligamentary  myoma,  or  an  intraligamentary  tubal  pregnancy,  or 
an  ovarian  cyst  :  it  grows  into  the  broad  lujamt'iitH.  The  L^rowth  is 
so  great  at  the  fundus  as  to  push  the  adnexa  and  ligaments  far 
down  toward  the  cervix.  The  ligaments  do  not  begin  to  tighten 
until  the  labor-pains  come.  on.  At  the  beginning  of  pregnancy  the 
volume  of  the  uterus  is  to  its  weight  as  1 :  14,  toward  the  end,  as 
6:1  (v.  Herff).  This  is  on  account  of  the  steady  growth  of  the 
uterine  tissues,  which  at  last,  however,  diminishes. 

During  the  puerperiuni  the  muscle-fibers  rapidly  undergo  a 
granular  degeneration.  Those  nearest  the  mucosa  (decidua)  take 
on  a  characteristic  zigzag  shape  (see  Fig.  87);  but  they  do  not 
return  to  their  original  size.  Other  newly  formed^  fibers  are 
reduced  to  a  minimum  size,  but  remain  as  a  reserve  supply.  This 
explains  why  the  uterus  after  involution  is  completed  is  still 
larger  than  in  the  virgin  state.  • 

Diirincr  pregnancy  the  uterus,  like  any  other  muscular 
organ,  possesses  a  definite  tone  ;  it  is,  however,  not  in  a 
state  of  uniform  contraction,  but  contracts  at  regular 
intervals  with  such  force  as  almost  to  compress  the 
organ  to  its  utmost,  especially  during  the  latter  half  of 
pregnancy,  although  the  contractions  are  sometimes  ob- 
served from  the  beginning  of  the  fourth  month.  These 
vigorous  contractions  make  it  impossible  for  the  fettis  to 
change  its  position  or  even  to  obey  the  laws  of  gravity, 
especially  when  labor  is  near  at  hand,  for  the  fetal  move- 
ments are  in  reality  very  weak,  and  only  appear  strong 
because  the  fetus  is  suspended  in  the  amniotic  fluid. 
Gravity  can  aifect  only  the  pregnant  uterus  as  a  whole. 
The  attitude  of  the  fetus  is  determined  neither  by  gravity 
alone  nor  by  its  own  spontaneous  or  reflex  movements, 
but  by  the  contrcictions  of  the  uterine  muscle  and  the 
■"  functional  ovoid  shape  '*  of  the  uterus.  The  head,  being 
the  most  compact  and  at  the  same  time  most  movable 
portion,  is  the  part  most  readily  acted  upon  ;  the  larger 
and  firmer  the  head  the  more  easily  it  is  forced  into  tiie 
lower  segment,  against  the  internal  os,  where  the  muscular 
layer  is  least  developed  and  there  is,  therefore,  least  ex- 
pulsive power.  At  the  same  time  the  rest  of  the  body 
and  the  extremities,  being  coiled  on  themselves,  are  best 
accommodated  in   the  broad,  oval  fundus    uteri,   which, 

5 


66  NORMAL   LABOR. 

therefore,  contains  the  trunk,  breech,  and  extremities,  while 
the  head  occupies  the  less  muscular  lower  uterine  seg- 
ment. Although  the  gravid  uterus  is  soft  and  doughy, 
and,  except  during  the  frequent,  imperceptible  contractions, 
represents  a  flabby,  yielding  sac,  yet  the  general  effect  of 
the  regularly  recurring  contractions  is  to  give  it  a  distinct 
oyal  shape  and  to  cause  the  fetus  to  assume  a  correspond- 
ing attitude.  As  the  contractions  are  not  always  uniform 
the  palpating  hand  feels  the  contracting  portions  now  as 
round,  hard  masses,  now  as  ridges  running  lengthwise  of 
the  organ. 

Distinct  ^' cephalic  presentations^' are  much  more  rare 
when  either  the  fetus  or  the  uterus  is  deformed  (uterus  uni- 
cornis or  bicornis,  partial  inertia  uteri),  or  the  head  is 
either  abnormally  small  or  enormously  enlarged. 

The  older  the  fetus  and  the  larger  and  firmer  the  head 
the  more  frequent  are  cephalic  presentations  in  premature 
births. 

Thus  the  long  axis  of  the  fetal  trunk  becomes  exactly 
perpendicular  to  the  plane  of  the  inlet  or  coincides  exactly 
with  the  long  diameter  of  the  uterus  and  a  cephalic  pre- 
i^entation  results.  In  two-thirds  of  all  cephalic  presenta- 
tions the  back  is  found  on  the  left  side  of  the  mother  and 
turns  to  the  left  and  forward  when  labor-pains  begin. 
This  is  called  the  fi7'st  presentation  (L.  O.  A.).  It  is  due 
to  the  fact  that  the  transverse  diameter  of  the  uterus,  as 
explained  above,  usually  coincides  Nvith  the  right  oblique 
diameter  of  the  pelvis  (B.),  so  that  its  left  border  is  felt 
in  front  through  the  abdominal  walls.  Another  reason  is 
that  the  lordosis  of  the  vertebral  column  in  the  later 
months  of  pregnancy  prevents  the  fetal  back  from  falling 
backward  into  the  right  half  of  the  uterus.  Until  the 
onset  of  labor-pains  the  position  of  the  back,  whether 
anterior  or  posterior,  is  determined  by  gravity  and  possibly, 
to  some  extent,  by  the  weight  of  the  fetal  liver ;  but  as 
soon  as  labor  begins  the  back  is  rotated /orz6''«rc?.  Another 
factor  is  the  site  of  the  placenta. 

In  funnel-shaped   pelves   with    lumbosacral   kyphosis, 


THE   UTERINE  MUSCLE  AND  ITS  FUNCTIONS.    67 

owing  to  the  ab-ence  of  lordosis,  the  first  and  second  pre- 
sentations (L.  O.  A  and  R.  O.  A.)  occur  with  e(|ual  fre- 
quency. It  is  said  that  among  Japanese  women  the 
second  ])resentation  (R.  O.  A.)  is  more  common  than  the 
first.  If,  as  rarely  happens,  the  uterus  is  displaced  to  the 
left  there  is  every  likelihood  that  the  occiput  has  been 
rotated  backward,  or  that  by  a  simultaneous  torsion  on  the 
other  side  a  second  cephalic  presentation  (R.  O.  A.)  will 
result. 

LABOR-PAINS   AND  THEIR   EFFECT  ON   THE   FETUS. 

In  contracting  the  uterus  approaches,  as  far  as  the 
ovum  permits,  the  pyriform  shape  of  the  virgin  state  :  it 
becomes  rigid,  increases  in  length  and  depth,  and  meeting 
the  resistance  of  the  lumbar  and  sacral  vertebrae  forces 
the  abdomincd  walls  forward.  The  body  of  the  uterus, 
being  a  holloiv  muscle,  contracts ;  the  lower  uterine  seg- 
ment— owing  to  the  absence  of-  muscular  tissue  or  in 
obedience  to  antagonistic  innervation — suffers  longitudinal 
distention.  The  lower  uterine  segment,  the  cervix,  and 
the  vagina  together  constitute  the  outlet  of  the  birth-canal. 
The  cervix  and  the  external  os  are  poor  in  muscle-fibers, 
but  rich  in  elastic  fibers.  The  latter  are  arranged  in  two 
layers,  an  outer  longitudinal  and  an  inner  circular  (like 
the  string  of  a  tobacco-pouch),  which  is  distended  by  the 
descent  of  the  head,  assisted  by  the  contraction  of  the 
longitudinal  or  retraction  fibers,  which  are  anatomically 
and  functionally  connected  w^ith  the  longitudinal  fibers 
of  the  uterus  and  with  the  round  ligaments.  There  is, 
in  fact,  a  true  sphincter,  consisting  not  of  muscular  but 
of  elastic  fibers.  The  cervical  canal  and  the  lower  uterine 
segment  undergo  during  labor  a  dilatation  equal  to  six 
times  the  natural  diameter  or  about  3J  in.  (8  cm.). 

The  contraction  of  the  hollow  muscle  and  the  pressure 
of  the  abdominal  walls,  in  combination  with  the  resisting 
forces  described,  result  in  a  general  internal  2)ressure  on 
the  fetus.  At  first  the  uterus  rises  about  a  finger's  breadth. 
The   lower    portion   of    the    birth-canal,    especially   the 


68  NORMAL  LABOR. 

"lower  uterine  segment,"  undergoes  longitudinal  disten- 
tion. This  has  the  effect  of  stretching  the  fetus  to  the 
extent  of  about  1 J  in.  (3 J  cm.),  as  has  been  proved  by 
frozen  sections ;  pressure  is  exerted  on  the  vertel)ral 
column  of  the  fetus  ('^  Fruchtwirbelsaulendruck^'). 

It  appears  to  me  that  this  theory  of  Lahs,  while  it  takes  due 
account  of  the  important  and  undeniable  phenomenon  of  the 
stretching  of  the  fetus  and  the  lengthening  of  the  uterus  during 
contraction,  neglects  thsit  other  force  by  which  the  uterus  returns  to  its 
original  fiat  tened^  pyriform  shape  with  slight  anteflexion.  This  force 
is  merely  one  of  the  components  of  the  general  internal  pressure. 
It  is  tacitly  included  in  the  force  which  Schatz  calls  the  "restitu- 
tion-force" ("Formrestitutionskraft")  of  the  uterus.^ 

Litra-uterine  pressure,  registered  in  the  plane  of  the  inlet  by 
means  of  a  hollow  rubber  ball  introduced  into  the  cervix  (after 
Schatz  and  Westermark),  depends  on  : 

(1)  The  abdominal  contractions  and  accidental  intra-abdominal 
tension,  such  as  gas,  etc.,  forming  together  the  intra-abdominal 
pressure  ; 

(2)  On  the  difference  in  level  between  the  pelvic  inlet  and  the  highest 
point  of  the  uterus  (varies  with  the  position  of  the  body ;  in  the 
dorsal  decubitus  it  is  30  mm.  Hg.) ;  and 

(3)  On  the  tension  of  the  uterine  walls :  volume  of  contents. 
Intra-uterine  pressure   diminishes   after   the    membranes   have 

ruptured ;  it  then  tends  to  regain  its  former  height,  but  is  pre- 
vented from  doing  so  by  the  discharge  of  the  amniotic  fluid  and 
the  descent  of  the  fetus.  The  severity  of  the  labor-pains  is  in 
direct  proportion  to  the  intra-uterine  pressure.  The  curve  at 
first  rises  very  slowly,  then  there  is  a  sudden  jump,  followed  by 
a  second  gradual  increase,  till  it  reaches  its  maximum  duration 
of  8.1  seconds.  The  fall  is  at  first  gradual,  then  more  rapid,  and 
finally  very  slow,  until  the  ordinate  is  reached. 

Intra-uterine  pressure  varies  between  20  and  220  mm.  Hg.  =  4  lb. 
6  J  oz.  and  55  lb.  2  oz.  (2  and  25  kilos) ;  the  mean  pressure  =  55. Q— 
163.3,  or  107  mm.  Hg.  (according  to  Schatz  the  maximum  is  100 
=2202-  lb.  [10  kilos]).  The  labor-pains  increase  progressively, 
being  greatest  at  the  end  of  labor.  According  to  Schatz's  toko- 
dynamometer  they  have  a  strength  of  18f  to  6lh  lb.  (8.5  to  27.5 
kilos).  They  travel  in  peristaltic  waves  from  the  tube  to  the 
internal  os. 

This  peristaltic  movement  was  observed  by  Kehrer  in  animals, 

^Schatz's  theory  differed  from  that  of  Lahs;  he  distinguished  the 
"general  uterine  pressure,"  the  "restitution-force"  of  the  uterus  and 
fetus,  and,  as  a  resultant  of  these  two,  the  "  pressure  along  the  axis  of 
the  fetus  "  ("  Fruchtachsendruck  "). 


THE    VTERINE  MUSCLE  AXD  ITS  FUNCTIOyS.         69 


CO     c+S     ri-  n      — ■i—iT' 


05 


03     O     ET    5     5^    3 


^.   i< 


O 


o 
o 


l-l 

p 


70 


NORMAL  LABOR. 


Fig.  5.— Eftective  terminal  bearing-down  pain. 


Fig.  6.— Double  pain,  one  a  bearing-down  pain,  followed  by  an  abortive 

pain. 


Fig.  7.— Intra- 
uterine pressure 
during  bearing- 
down  pains  (after 
Schatz,  for  com- 
parison with  the 
curves  after  au- 
thor's method,  in 
Figs.  4-6,  8,  and 
10). 


THE   UTERINE  MUSCLE  AND   ITS  FUNCTIONS. 


71 


Last  pain  in  dorsal 
decubitus  with 
bearing  down. 


c 

OD 


CI 

c 


cr 
cr 

o 


Head     in     vulva.       rf; 

< — «  Patient  placed       1 

in  side  position.       2; 


Bearing  down  during 
interval. 


Labor-pain  without 
bearing  down. 

< — ^  Birth  of  head. 

Bearing  down  during 
interval. 

Last  labor-pain. 
Birth  of  child 


72  NORMAL  LABOR. 

and  by  v.  HerfF  in  women  during  Cesarean  sections.     Ahlfeld,  on 
the  other  hand,  did  not  observe  it. 

The  author  has  studied  the  more  delicate  variations  in  the  con- 
tracting uterus  in  the  different  periods  of  labor  by  means  of  a 
helmet-like  contrivance  applied  to  the  fundus  uteri,  which,  by 
means  of  a  closed  pneumatic  apparatus  and  gasometers,  trans- 
ferred the  rise  and  fall  during  labor-pains  and  in  the  intervals 
between  them  to  a  drum.^  Toward  the  end  of  the  first  stage  the 
pains  increase  in  strength  and  duration,  the  intervals  become 
shorter,  and  "  complex "  curves  are  more  frequent  (there  are 
typical,  simple  labor-pains  in  the  beginning  of  labor  and  more 
complete  ones,  double  and  multiple  pains,  and  typical  pains  in 
groups).  These  curves  are  not  influenced  at  all  by  rupture  of  the 
membranes,  but  undergo  a  decided  change  when  the  head  begins  to 
emerge  from  the  fully  dilated  os.  The  maximum  duration  reached 
at  tliis  time  remains  unchanged  throughout  the  second  stage;  but 
the  apex  of  the  curve  rises  still  higher  toward  the  end  of  this 
stage,  the  intervals  become  yet  shorter,  and  the  duration  of  the 
individual  pains  varies  much  more  than  during  the  first  stage. 
The  author's  curves  show  a  Mt, plateau-like  apex  (in  harmony  with 
older  authors  and  Westermark,  but  contrary  to  Schatz)  for  the 
second  stage  of  labor  : 

Beginning  of  labor-pain,     0-50    seconds,    average  15.8  seconds. 
Maximum  duration,  14-75        "  "      35.2 

Decline,  3-100      "  "      32.9 

Westermark  gives  a  maximum  duration  of  2  to  29  seconds 
(8.1  sec.  on  the  average) ;  it  merely  shows  that  the  uterus  requires 
a  longer  time  to  return  to  a  position  and  shape  of  rest  than  the 
effect  of  the  contraction  on  the  internal  pressure  lasts. 

These  investigations  have  a  practical  value  for  the  estimation 
of  atonic  and  partially  tetanic  labor-pains. 

The  onset  of  labor,  m  other  ^Yords,  the  duration  of 
pregnancy,  appears  to  depend  on  that  regularly  recurring 
cycle  of  rnetaboHsm,  circulation,  and  innervation  in  which 
the  sexual  life  of  a  woman  finds  its  expression. 

Two  hundred  and  eighty  days,  or  ten  lunar  months, 
is  tlie  mean  duration  that  is  usually  accepted,  so  that  the 
tenth  menstrual  determination  to  the  genitalia  is  the 
immediate  cause  of  labor,  which  is,  however,  assisted  by 
sundry    external     influences    calling    forth    labor-pains. 

1  A  few  of  the  most  instructive  curves  have  been  reproduced  from  a 
pamphlet  published  by  Hirschwald,  Berlin,  1896:  "  Activity  of  Labor- 
pains,"  etc, 


THE   UTERINE  MUSCLE  AND  ITS  FUNCTIONS.     73 

DcUvery  at  term  may  occur  between  the  thirty-eighth 
and  forty-first  week  ;  premature  labor  from  tlie  twenty- 
eighth  to  the  thirty-eighth  week  (the  child  can  be  reared 
with  proper  care);  miscarriage  or  premature  labor  from 
the  sixteenth  to  the  twenty-eighth  week  (the  child  is  not 
viable,  although  the  heart  may  continue  to  beat  a  few 
minutes  or  even  hours  ;  the  placenta  serotina,  as  such,  is 
completed  in  the  beginning  of  the  fourth  month) ;  abor- 
tioiij  that  is,  the  discharge  of  an  ovum  prior  to  the  com- 
plete formation  of  the  placenta,  up  to  the  sixteenth  week. 
Pregnancy  may  be  prolonged  to  three  hundred  days 
(partus  serotinus  after  the  forty-first  week)  ;  in  such  cases 
the  child  is  usually  very  large.  Missed  labor  is  the  term 
applied  to  cases  in  which,  labor  having  begun,  the  pains 
cease  and  the  fetus  is  not  expelled. 

It  appears,  then,  that  the  onset  of  labor  is  regulated  by  a  central 
mechanism.  Among  the  co-operating  factors,  none  of  which  in 
itself  suffices  to  bring  on  labor,  are:  the  overdistention  of  the 
uterus  by  the  fully  matured  fetus ;  tlie  pressure  exerted  by  the  latter 
on  the  internal  os  ;  the  accumulation  of  products  of  fetal  metab- 
olism, especially  CO,,  in  the  maternal  tissues,  due  to  a  change  in 
the  course  of  the  inferior  vena  cava  of  the  child,  which  at  the  end 
of  pregnancy  empties  into  the  right  auricle,  so  that  the  head 
receives  only  venous  blood  ;  and,  finally,  thrombosis  in  the  placen- 
tal veins  and  necrobiosis  of  the  decidua.  The  proximate  exciting 
impulse  to  labor-pains  is  derived  principally  from  the  paracervical 
ganglia,  although  there  is  also  a  regulating  center  in  the  lumbar 
cord. 

Our  knowledge  of  the  nerve-supply  of  the  sexual  apparatus 
amounts  to  this:  The  uterus  is  innervated  by  three  sets  of  nerves  : 
ia)  one  set  derived  from  the  cord  and  passing  through  the  sacral 
nerves  (which  cause  the  dolores  conquassanfes  when  the  head  passes 
the  vulva)  to  the  lateral  ganglia  of  the  cervix  in  the  posterior  fornix ; 
[b)  sympathetic  fibers  from  the  aortic,  mesenteric,  and  hypogastric 
(on  the  promontory)  plexuses,  joining  the  uterine  plexus  on  the 
aorta;  (c)  independent  ganglia — Dembo's  ganglia — in  the  anterior 
fornix  (Fig.  68). 

All  three  sets  contain  both  motor  and  sensory  fibers,  but  the 
sacral  nerves  contain  principally  afferent  inhibitory  fibers.  Pe- 
ripheral irritation  of  the  ovarian  nerves  gives  rise  to  marked 
uterine  movements. 

Uterine  contractions  may  be  incited  by  sudden  and  great 


74  NOBMAL  LABOR. 

Fig.  68.  Nerve-supply  of  the  Female  Genitalia  (modified  from  Frank- 
euhauser  and  Hirschfeld) :  1,  inferior  aortic  hypogastric  plexus  ;  2,  right 
inferior  mesenteric  plexus;  3,  lumbar  ganglion  of  sympathetic  nerve; 
4,  ovarian  plexus  (from  renal  and  aortic  plexuses),  supplies  tubes,  ovaries, 
and  fundus  uteri;  5,  third  and  fourth  sacral  nerves  form  the  right  infe- 
rior hypogastric  plexus  with  the  ganglionic  systems  6  and  7,  which 
supply  the  cervix;  8,  uterine  nerves;  the  lower  part  of  the  uterus  is 
supplied  by  the  inferior  hypogastric  plexus,  the  middle  portion  by  the 
inferior  aortic  hypogastric  plexus,  the  fundus  by  the  ovarian  plexus  and 
filaments  from  the  two  last-named  plexuses  ;  9,  vesical  plexus  ;  10,  sciatic 
nerve;  11,  branch  of  fourth  sacral  nerve  to  levator  ani;  12,  pudic  nerve; 
13,  its  continuation  as  dorsal  nerve  of  the  clitoris  ;  R,  rectum  ;  U,  uterus  ; 
B,  bladder;  D,  transversus perinei  muscle  (in  cross-section) ;  8,  iliac  bone; 
P,  OS  pubis;  Ur,  ureter;  Ao,  aorta;  V,  vagina;  La,  levator  ani  muscle;  Ov, 
ovary ;  T,  tube. 

Fig.  69.  Muscles  of  the  Perineum  (original  drawing,  modified  from 
Savage,  with  corrections) :  1,  gluteus  maximus  ;  2,  levator  ani ;  3,  sphincter 
ani;  4,  obturator  externus ;  5,  tubera  ischii;  6,  ischiocavernosus  and  erector 
clitoridis ;  7,  constrictor  vaginx ;  8,  coccyx;  9,  symphysis  and  suspensory 
ligament  of  the  clitoris;  10,  gland  of  Bartholin  ;  11,  anus ;  12,  vagina; 
13,  urethra;  14,  the  connective  tissue  and  fascia  shown  in  Fig.  30,  6,  7; 
15,  great  sacrosciatic  ligament. 

loss  of  blood,  by  an  excess  of  CO^  in  the  general  circula- 
tion, by  high,  febrile  temperatures,  by  quinine,  sodium 
salicylate,  ergot,  and  other  poisons  (strychnine),  and  by 
experimental  irritation  of  the  ovarian  nerves  belonging  to 
the  ovarian  plexus  (formed  by  branches  of  the  renal  and 
aortic  plexuses)  and  functionally  connected  with  the 
uterus  and  uterine  plexus  by  means  of  the  two  ovarian 
ganglia.  The  entire  sympathetic  system  of  the  genital 
organs  can  be  traced  back  to  the  celiac  ganglion,  Avhich, 
as  is  well  known,  contains  fibers  from  the  vagi.  Lastly, 
labor-pains  may  be  excited  by  direct  irritation  of  the  uterus; 
this  acts  reflexly,  hence  the  resulting  pain  induces  the 
contractions  which  follow  ;  on  the  other  hand,  uterine  con- 
tractions may  also  be  induced  by  independent  centers  in 
the  uterus,  without  the  intervention  of  the  central  nervous 
system  (Fig.  68).  There  is  also  a  reflex  communication 
between  the  mammae  and  the  uterus. 

The  uterine  nerves  are  most  irritable  at  the  end  and 
at  the  very  beginning  of  pregnancy  ;  during  the  entire 


THE  FIRST  OR  DTLATATION  STAG?:  OF  LABOR.    Ir) 

period  they  are  thickened  by  an  overgrowth  of  connective 
tissue.  It  has  been  experimentally  proven  that  conception 
and  parturition  are  })ossil)le  after  complete  destruction  of 
the  lumbar  cord.  This  has  even  been  observed  in  women 
after  all  connection  with  the  higher  portions  of  the  cord 
and  the  cerebrum  had  been  severed,  as  in  paraplegia, 
echinococcus,  neoplasm  on  a  thoracic  vertebra,  etc.  The 
innervation  is  probably  derived  from  Dembo's  centers. 
The  uterus  itself  contains  no  ganglia,  but  numerous  cellu- 
lar elements  of  various  shapes  are  found  embedded  in  a 
network  of  sympathetic  fibers  anastomosing  with  them 
and  with  each  other.  In  addition  to  and  separate  from 
these  there  are  long  medullated  cerebrospinal  fibers  run- 
ning through  the  uterine  substance. 

The  sensory  nerves  of  the  vagina  and  vulva  also  par- 
ticipate in  the  act  of  parturition,  as  in  other  generative 
processes,  by  virtue  of  their  influence  on  labor-pains  and 
on  the  musculature  of  the  vagina.  These  parts  are  sup- 
plied by  the  pudic  nerve  and  its  branch  to  the  clitoris ; 
irritation  of  them  is  follow^ed  by  engorgement  of  the 
vessels  of  the  cervix,  vagina,  and  vulva  (through  the 
inferior  hypogastric  plexus),  and  by  contraction  of  the 
constrictor  vagince,  levator  ani,  and  all  the  muscles  that 
enter  into  the  formation  of  the  pelvic  floor  (through  the 
sacral  nerves),  and  play  such  an  important  role  during  the 
passage  of  the  presenting  part. 

§  6.  THE  FIRST  OR  DILATATION  STAGE  OF  LABOR. 
BEHAVIOR  OF  THE  LOWER  UTERINE  SEGMENT  AND 
OF  THE  CERVIX  DURING  THIS  PERIOD. 

As  a  rule,  the  cervix  takes  no  part  in  the  support  of 
the  ovum  during  pregnancy  ;  at  most  some  decidual  cells 
may  be  found  a  few  millimeters  below  the  internal  os, 
hence  the  l)ody  of  the  uterus  proper  only  is  adapted  to 
the  reception  of  the  ovum.  The  entire  cervix  remains 
unaltered  until  the  onset  of  labor,  the  shortening  of  the 
vaginal  jortion  being  the  only  apparent  change,  as  shown 
in  §  2.     In  the  cases  in  which,  owing  to  slight  dilatation 


76  NORMAL  LABOR. 

of  the  (anatomical)  internal  os,  the  portion  immediately 
l)elow  it  becomes  the  seat  of  deciclua-formation,  the  boun- 
dary of  the  cervical  mucosa  is  marked  by  a  slight  thick- 
ening, known  as  Muller's  ring.  In  primiparse,  however, 
the  internal  os  and  the  upper  portion  of  the  cervical  canal 
do,  toward  the  end  of  pregnancy,  participate  in  the  dilata- 
tion of  the  lower  uterine  segment. 

With  the  onset  of  labor-pains  the  muscularis  of  the 
body  of  the  uterus  contracts  over  the  child  in  a  direction 
toward  the  fundus,  so  that  a  propulsive  force  is  exerted 
along  the  longitudinal  axis  of  the  child  toward  the  true 
pelvis,  except  in  transverse  presentations.  But,  since  the 
child  is  propelled  forward,  the  uterine  muscle  must  find  a 
point  cVappid  in  the  maternal  body  as  soon  as  the  present- 
ing part  meets  with  resistance,  as  at  the  brim,  at  the  rectum 
distended  with  feces  or  at  a  distended  bladder,  at  the 
iliacus  and  psoas  muscles,  at  the  surfaces  of  the  acetabula, 
at  the  spines  of  the  ischium,  at  the  levatores  ani  and  con- 
strictor vaginae,  at  the  coccyx,  at  the  perineum,  and  at 
the  symphysis. 

When  the  uterus  is  forcibly  contracted  to  overcome 
abnormal  resistance,  such  as  that  offered  by  a  contracted 
pelvis  for  instance,  this  line  of  fixation  must  coincide  with 
the  lower  boundary  of  that  portion  of  the  genital  tube 
which  suffers  the  greatest  longitudinal  distention  when 
the  contracting  force  of  the  fundus  is  exerted  ;  [that  is  to 
say,  the  lower  uterine  segment,  as  will  appear  in  the  next 
paragraph. — Trans.] 

The  recently  evacuated  uterus  ^  of  a  woman  who  has 
died  during  childbirth  ])resents  two  distinct  divisions:  the 
contracting  uterine  body  with  thick  walls,  and  a  thinner 
portion  extending  to  the  external  os.  The  pregnant  con- 
tracting uterus,  before  dilatation  of  the  internal  os^  has 
occurred,  presents  three  more  or  less  distinct  zones  :  the 
contracted   upper   part  of   the   body ;  a  distended   lower 

^  Bvaune's  frozen  section  of  a  parturient  woman  {Y\^.  4,  in  Ailas  of 
Obstetrics,  I.,  niodified)  in  the  second  stage  of  labor;  Schroder's  speci' 
men  of  a  woman  just  delivered  (1886  . 

2  Schroder-Stratz  (1886),  frozen  section. 


THE  FIRST  OR  DILATATION  STAGE  OF  LABOR.    77 

portion,  the  so-callod  "  lower  uterine  segment,"  about  2|- 
in.  (7  cm.)  in  leno'th,  extending  to  the  internal  os ;  and 
the  intact  cervical  canal.  The  lower  boundary  of  the 
contracting  zone  of  the  fundus  is  marked  by  a  ridge  of 
thickening,  the '' contraction-ring,"  which,  however,  can 
rarely  be  distinctly  recognized  as  a  persistent  element  even 
in  the  living  subject,  and  practically  never  in  the  cadaver. 
It  follows  that  the  entire  genital  canal  below  the  contrac- 
tion-ring undergoes  lateral  distention  during  labor,  wliile 
true  longitudinal  distention  can  take  place  only  in  the 
above-mentioned  region,  extending  from  the  internal  os 
to  the  contraction-ring  ;  this  part  of  the  uterine  body  is, 
therefore,  the  true  '•  lower  uterine  segment."  It  is  stretched 
by  traction,  while  the  cervical  canal  and  vagina,  with 
ordinary  or  slightly  increased  resistance,  represent  the 
dilated  portion  of  the  birth-canal,  that  part  which  is  sim- 
ply thinned  by  the  pressure  on  its  walls  from  within. 
But  under  abnormal  conditions  of  resistance  this  latter 
portion  may  partially  assume  the  character  of  a  distended 
segment;  in  other  words,  in  forced  contractions  the  genital 
canal  seeks  a  deeper  point  of  fixation.  The  first  or  upper 
point  of  fixation  is  found,  as  we  have  shown,  in  the  region 
about  the  internal  os  ;  the  manner  of  its  attachment  will 
be  studied  later.  What,  then,  is  the  second  more  deeply 
situated  point  of  fixation  ? 

Among  the  many  specimens  of  rupture  of  the  uterus 
in  the  Munich  Gynecological  Clinic  the  line  of  rupture  in 
most  cases  was  longitudinal  or  oblique,  or  in  the  form  of 
a  transverse  tear  with  a  long  triangular  flap  pointing 
downward,  beginning  above  at  the  contraction-ring  and 
ending  below  at  a  point  4-  to  4-  in.  (0.5  to  2  cm.)  above 
the  external  os  (see  Fig.  16  in  the  text).  In  some  of  the 
specimens  the  tear  is  continued  directly  into  the  vagina, 
but  more  frequently  it  ends  at  the  above-mentioned  point 
in  the  cervical  canal,  leaves  the  os  intact,  and  is  then  con- 
tinued into  the  vaginal  vault.  It  is  evident,  therefore, 
that  there  are  three  'Hower  points  of  fixation":  (a)  at  the 
level  of  the  cervix,  i.  e.,  at  the  internal  os,  under  normal 


78  NORMAL  LABOR. 

conditions;  (b)  about  ^  to  |-  in.  (0.5  to  2  cm.)  above  the 
internal  os  (in  puerperal  specimens)  when  the  pressure  is 
abnormally  increased ;  (c)  in  the  vaginal  vault. 

These  phenomena  find  a,  partial  explanation  in  the  anatomical 
structure  of  the  parts.  In  [a)  fixation  is  effected  by  the  muscular 
fibers  and  thick,  tendinous  bundles  of  connective  tissue,  which  are 
found  partly  in  the  retro-uterine  peritoneal  folds  of  Douglas  and 
partly  in  the  lower,  basal  portions  of  the  broad  ligaments,  from  the 
level  of  the  internal  os  downward  as  far  as  the  fornix,  enclosing 
the  genital  canal  and  fixing  it  to  the  pelvic  wall.  These  glisten- 
ing, tendinous  bands  of  connective  tissue  constitute  what  is 
known  as  the  llgamentum  cardinale  (Kock),  and  merge  into  the 
sacrorecto-uterine  and  pubovesico-uterine  ligaments  and  the  tis- 
sues forming  the  lateral  walls  of  the  pelvis  (see  Fig.  75). 

Above  the  cross  formed  by  these  ligamentary  bands  the  uterus 
is  loosely  attached  to  the  adjoining  organs  by  areolar  tissue,  such 
as  is  found  under  a  serous  surface  ;  it  lies  beneath  that  part  of 
the  serous  membrane  which  lines  the  vesico-uterine  and  recto- 
uterine fossae  in  front  of  and  behind  the  uterus,  the  lateral  por- 
tions forming  part  of  the  broad  ligaments.  The  latter  represent 
the  mesentery  of  the  internal  sexual  organs;  during  pregnancy 
their  bulk  is  much  increased  by  the  hyperemia  of  the  vascular 
system.  In  the  same  way  the  peritoneum  increases  in  thickness 
and  extent  in  all  parts  of  the  genital  tract,  both  by  virtue  of  its 
elasticity  and  power  of  adapting  itself  to  the  uterus  and  by 
actual  cell-proliferation.  The  peritoneum  extends  from  the 
bladder  to  the  internal  os  or  a  little  higher,  forming  the  excava- 
tion bounded  by  the  vesico-uterine  folds.  Below  the  peritoneum 
the  connection  between  the  uterus  and  bladder  is  maintained  by 
loose  connective  tissue. 

The  body  of  the  uterus  is,  therefore,  covered  by  peritoneum, 
forming  the  closely  adherent  "  perimetrium,"  which  is  continued 
to  the  pelvic  walls  on  each  side  as  the  broad  ligament.  The 
upper  border  lodges  the  oviduct,  covered  by  a  duplicature  of  the 
membrane  which  is  continued  to  the  linea  terminalis  as  the  sus- 
pensory ligament  of  the  ovary  (infundibulopelvic  ligament). 
The  ovary  and  parovarium  occupy  the  posterior  surface  of  the 
broad  ligament,  but  are  not  completely  enclosed  by  it.  The  loose 
connective  tissue  and  the  blood-vessels  are  found  between  the  two 
serous  layers.  The  infundibulopelvic  ligament  arches  backw^ard 
to  the  brim  of  the  pelvis,  where  it  is  inserted  above  the  bifurca- 
tion of  the  common  iliac  artery.  From  this  point  the  broad 
ligament  sweeps  forward  and  backward  and  descends  with  the 
hypogastric  artery. 

In  close  relation  with  the  hypogastric  arteries  are  found  the 
ureters,  which  describe  a  curve  with  its  convexity  outward  and 


THE  FIRST  OR  DILATATION  STAGE  OF  LABOR.    79 

backward,  and  descend  obliquely  from  without  inward  and  from 
behind  forward  to  the  base  of  the  broad  ligament.  The  left 
ureter  is  near  the  median  line,  but  the  right  is  nearer  the  internal 
OS  (f  in.  =  19  mm.),  on  account  of  the  dextroposition  of  the  uterus 
from  the  pressure  of  the  rectum;  it  is  only  |  in.  (8  mm.)  from 
the  supravaginal  portion  of  the  cervix  and  \  in.  (6  mm.)  from 
the  vaginal  vault.  At  a  point -^  in.  (15  mm.)  lower  down  the 
ureters  are  found  on  the  anterolateral  wall  of  the  vagina,  which 
they  cross  at  an  acute  angle. 

The  peritoneum  leaves  the  posterior  surface  of  the  uterus  at 
about  the  level  of  the  internal  os,  after  forming  at  this  point  a 
thickened  ridge  (Figs.  29,  32),  which  contains  numerous  muscle- 
fibers  and  is  continued  into  the  sacro-uterine  and  recto-uterine 
folds  of  Douglas.  These  fibers  form  the  so-called  reiradores  uteri 
of  Luschka.  Immediately  below  is  the  attachment  of  the  above- 
described  intersecting  ligaments,  the  lateral  portions  of  which 
also  contain  smooth  muscle-fibers. 

The  peritoneum  dips  down  f  to  4  in.  (1  to  2  cm.)  below  Douglas' 
folds  into  the  recto-uterine  or  Douglas'  pouch,  as  far  as  the  pos- 
terior ibrnix  (hence  lower  than  in  front),  and  from  this  point  is 
reflected  back  over  the  rectum  and  to  the  posterior  pelvic  wall. 

Beneath  the  peritoneum  of  the  broad  ligament  the  round  liga- 
ment forms  a  distinct  ridge,  which  passes  on  either  side  from  the 
junction  of  the  tube  downward,  forward,  and  outward  through 
the  inguinal  canal.  Here  it  receives  a  tubular  extension  of 
peritoneum,  the  canal  of  Nuck  {processus  vaginalis  per itonealis). 
Emerging  from  the  external  abdominal  ring  it  passes  to  the  mons 
veneris,  where  it  receives  striated  muscle-fibers  from  the  internal 
oblique.  The  uterine  extremity  contains  smooth  muscle-fibers. 
During  pregnancy  the  round  ligament  enlarges  to  the  thickness 
of  a  finger,  partly  from  increase  of  the  muscular  portions.  As 
the  uterus  rises  above  the  inlet  the  course  of  the  round  ligaments 
and  of  the  oviducts  approaches  the  perpendicular,  although  the 
fundus  still  arches  over  far  above  them.  During  parturition  the 
ligaments  are  stretched  and  the  left  one  is  easily  palpated,  as  the 
uterus  rotates  into  the  right  diagonal. 

From  the  foregoing  description  it  follows  that  the  space 
on  either  side  of  the  uterus,  as  far  down  as  the  internal 
OS,  contains  only  a  loose,  non-resistant  connective  tissue, 
while  below  the  internal  os,  as  far  as  the  fornix,  is 
attached  the  more  resistant  lie/amentum  cardinale^  con- 
taining muscular  fibers  and  forming  the  first  point  of  fixa- 
tion mentioned  under  (a),  in  the  longitudinal  extension  of 
the  lower  uterine  segment. 


80  NORMAL  LABOR. 

At  the  second  j^oint  of  fixation  (b),  3-  to  f  in.  (^  to  2  cm.) 
above  the  external  os  in  the  cervix,  the  tension  increases 
until  the  bridge  of  tissue  connecting  the  vault  of  the 
vagina  with  the  nearest  point  of  the  cervix  is  stretched  to 
the  utmost ;  the  resistance  is  then  supplied  by  the  walls 
of  the  fornix,  which  are  fixed  by  the  closely  adherent 
peritoneal  fold  at  the  deepest  part  of  Douglas'  pouch 
(Figs.  17,  18,  27).  Hence,  if  the  uterus  ruptures,  the 
tear  either  extends  to  the  above-mentioned  point  in  the 
cervix  nearest  the  fornix,  -|-  to  |-  in.  (^  to  2  cm.)  above  the 
external  os,  or  it  passes  from  this  point  directly  into  the 
vault  of  the  vagina  (the  external  os  may  or  may  not 
escape),  since  the  latter,  like  the  cervix,  is  quite  firmly 
supported  by  tendinous  bands  of  connective  tissue  extend- 
ing in  all  directions,  especially  to  the  sacrum  ;  the  vault 
of  the  vagina  then  corresponds  to  the  third  jjoint  of  fixa- 
tion which  we  have  designated  (c). 

But  neither  the  fact  that  the  cervix  and  vagina  have  a 
common  mode  of  fixation  nor  their  close  anatomical  rela- 
tion suffices  to  explain  why  these  two  structures  are 
usually  torn  to  the  exclusion  of  the  external  os ;  a  third 
and  very  important  reason  is  that  both  are  subject  to  the 
same  muscular  pull,  since  the  greater  part  of  the  cervical 
fibers  pass  directh/  over  the  fornix  and  blend  rvith  the 
lonr/itudinal  fibers  of  the  vagina. 

Lastly,  tlie  position  and  direction  of  the  tear  de])end  on 
the  position  of  the  presenting  part,  over  which  the 
attenuated  uterine  wall  is  stretched.'  By  the  counter- 
pressure  of  a  second  force  the  original  simple  traction  is 
converted  by  leverage  into  a  more  powerful  resultant. 

There  are  several  reasons  why  it  is  a  priori  doubtful 
whether  fixation  takes  place  at  any  deeper  points^  when 
the  head  forcibly  engages  in  the  superior  strait.     In  the 

1  Among  100  cases  of  total  rupture  of  the  uterus  with  complete  escape 
of  the  child,  I  found  43  anterior,  17  posterior,  11  lateral.  The  remainder 
were  due  to  violence,  old  Cesarean  scars,  myoma-insertions,  etc. 

2  Such  fixationis  afforded  hy  the  constrictor  va^inse  and  levator  ani 
muscles,  which  serve  to  prevent  total  prolapse  in  the  hijihest  degree  of 
inversion  of  the  uterus  with  inversion  of  the  vagina  (see  Fig.  30). 


THE  FIRST  OR  DILATATION  STAGE  OF  LABOR.   81 

first  place  the  advancing  head  wedges  the  walls  of  the 
parturient  canal  fast  at  the  inlet  (thus,  the  fold  in  front  of 
the  head  seen  in  Braune's  frozen  section  of  a  parturient 
woman  is,  I  think,  due  to  the  relaxation  of  the  previously 
contracted  tissues,  cf.  PL  49) ;  then  the  vagina,  following  the 
line  of  the  parturient  canal,  is  concave  forward,  and  this 
curve  would  first  have  to  be  reduced  before  the  structure 
could  take  part  in  the  longitudinal  distention  ;  and  finally, 
after  the  largest  diameter  of  the  head  has  passed  the  inlet, 
the  presenting  portion  is  only  at  the  level  of  the  spines  of 
the  ischium,  that  is  to  say,  the  greater  part  of  it  is  still 
within  the  cervical  canal,  above  the  point  (^c),  which  marks 
the  fixation-point  of  the  vagina.  As  a  matter  of  fact 
such  lacerations  of  the  vagina  never  occur  as  a  result  of 
excessive  longitudinal  distention,  even  when  the  resistance 
is  situated  lower  than  the  inlet.  Thus,  in  funnel-shaped 
pelves,  where  the  contraction  is  situated  at  the  outlet, 
vaginal  tears  occur  only  from  circumscribed  pressure- 
necrosis  or  from  violence. 

The  ''  lower  uterine  segment "  then  exists  as  such  as 
early  as  the  first  half  of  ])regnancy.  According  to  some 
authors  (Hofmeier,  von  Franque,  Ruge,  Veit)  it  exists  as 
an  anatomical  structure  even  in  the  virgin  state,  the 
above-mentioned  authors  basing  their  belief  on  the  rela- 
tion of  the  anterior  peritoneal  attachment  and  of  the 
uterine  vessels  to  the  contraction-ring.  There  is  an  active 
growth  in  this  region  during  pregnancy.  The  internal  os 
must  be  regarded  as  the  lower  boundary  of  the  "  lower 
uterine  segment '';  this  view,  it  seems  to  me,  finds  further 
support  in  the  fact  that  decidua  formation  ceases  at  this 
point ;  in  the  fact  that  the  internal  os  remains  closed 
until  the  onset  of  labor ;  and  especially  in  the  fact  that 
on  this  assumption  the  inferior  fixation  of  the  uterus  in 
an  obstetrical  sense  takes  place  at  this  point.  The  con- 
traction-ring which  forms  the  upper  boundary  must  also 
be  considered  an  anatomical  part  of  the  body  of  the 
uterus,  but  its  shape  and  significance  are  brought  out 
only  by  the  contraction  of  the  muscularis  of  the  fundus 

6 


82  NORMAL  LABOR. 

and  body  ;  it  is  conspicuous  in  direct  proportion  to  the 
number  of  muscle-fibers  in  the  uterine  walls  above  the 
internal  os  and  the  strength  of  the  contractions.  The 
cervix  contains  few  muscle-fibers  and,  therefore,  does  not 
contract ;  on  the  other  hand,  it  suffers  little  or  no  elonga- 
tion during  pregnancy,  and  the  increase  in  thickness  is  due 
more  to  edematous  swelling  and  relaxation  of  the  tissues 
than  to  an  increase  in  the  muscle-fibers.  It  follows  that 
the  upper  limit  of  the  ''lower  uterine  segment^'  depends 
on  the  function  of  the  muscularis,  and  we  should  expect 
to  find  it  in  this  structure  at  the  point  where  the  muscle- 
fibers,  in  respect  to  number  and  arrangement,  begin  to 
assume  the  character  of  the  muscularis  at  the  fundus. 
This  zone  coincides  approximately  with  the  line  of  attach- 
ment of  the  anterior  perimetrium  and  the  entrance  of  the 
uterine  artery.  This  definition  will  be  found  in  the  1894 
edition  of  this  Atlas ;  v.  HerflP  adopted  the  same  view  in 
1897  ;  and  v.  Dittel  in  1898  was  forced  to  the  same  con- 
clusion by  his  histological  investigations.  It  is  for  this 
reason  that  the  contraction-ring,  representing  as  it  does  a 
function  which  ceases  with  life,  is  so  rarely  seen  in  the 
cadaver.  When  v.  Herff  found  it  in  a  Cesarean  section 
he  described  it  as  a  "  contraction-phenomenon,'^  which,  as 
such,  is  of  the  greatest  practical  significance. 

So  far  we  have  considered  only  the  anatomical  charac- 
ters of  the  parturient  canal.  In  regard  to  the  fetus  and 
the  part  it  plays  in  the  process  we  now  know  the  fol- 
lowing facts  :  (1)  The  trunk  suffers  extension  during  the 
uterine  contractions  ;  (2)  it  presents  a  jwint  (Fappui  to 
the  fundus  which  rises  above  it  as  it  contracts  ;  (3)  the 
advancing  head,  even  before  the  onset  of  labor,  follows 
the  line  of  least  muscular  resistance  and  is  pushed  into 
the  "  lower  uterine  segment.'^ 

During  the  dilatation  stage  the  head  burrows  down 
into  the  anterior  wall  of  the  lower  uterine  segment, 
which  it  pushes  before  it  into  the  vault  of  the  vagina. 
A  part  of  its  advancing  segment  is,  therefore,  deeper 
than  the  internal  or  even  the  external  os.     In  a  normal 


THE  FIRST  OR  DILATATION  STAGE  OF  LABOR.    83 

birth  the  bag  of  waters  is  still  intact  at  this  stage,  and  as 
it  is  forced  into  the  cervical  canal  dilates  the  latter  com- 
pletely. But  if  the  membranes  are  ruptured  prematurely, 
the  dilatation  of  the  cervix  must  be  effected  by  the  hard, 
unresisting  head,  and  is  accordingly  more  painful;  be- 
sides, the  head  becomes  much  more  firmly  fixed  by  ad- 
hesion in  the  anterior,  bulging  portion  of  the  ^'  lower 
uterine  segment."  This  may  give  rise  to  disturbances  of 
the  circulation,  edematous  swelling  of  the  tissues  about 
the  OS,  and  partial  contraction-spasms.  The  dilatation 
of  the  cervix  is  heralded  during  the  latter  part  of  preg- 
nancy by  a  softening  of  the  walls  progressing  from  above 
downward. 

If  the  inlet  is  contracted,  the  muscularis  of  the 
fundus,  on  the  one  hand,  is  unable  to  force  the  head 
into  the  inlet,  and  the  cervix,  on  the  other  hand,  being 
wedged  in  and  held  fast  by  the  head,  cannot  respond  to 
the  upward  pull  of  the  uterine  muscle.  In  such  cases 
the  above-described  tendinous  ligaments,  which  sur- 
round the  cervix  and  vagina,  do  not  come  into  action  at 
all,  the  lower  uterine  segment  is  held  fast  by  the  head 
itself  and  is  stretched  upward  ;  it  gives  way  at  the  point 
where  the  tension  is  greatest,  i.  e.,  opposite  the  vault  of 
the  cranium. 

To  sum  up  the  function  of  the  ^Mower  uterine  seg- 
ment," it  forms  that  part  of  the  uterus  which  receives  the 
presenting  part  (head)  of  the  fetus  and  allows  it  to  de- 
scend at  the  onset  of  labor.  The  effect  of  this  is  that 
the  cervical  canal  is  at  the  same  time  directly  dilated  by 
the  advancing  membranes,  or,  if  the  latter  have  ruptured 
prematurely,  indirectly  by  the  pull  of  the  uterine  walls 
and  the  pressure  of  the  head  on  the  anterior,  bulging 
portion  of  the  ^^  lower  uterine  segment."  The  latter  can 
perform  its  office  only  wdien  its  contractile  power,  or  in 
other  words,  its  muscular  development,  is  much  less  than 
that  of  the  fundus.  Hence,  it  begins  where  the  muscu- 
laris of  the  fundus  ends ;  when  the  organ  is  firmly  con- 
tracted the  thickness  of  the  walls  diminishes  abruptly, 


84  NORMAL  LABOR. 

Fig.  70.  Tlie  Pelvic  Inlet ;  its  Diameters  and  their  Average  Normal 
Lengths,  and  its  Musculature  (70-72,  modified  after  Veit)  :  1,  body  of 
the  first  sacral  vertebra  ;  2,  symphysis  ;  5,  obturator  foramen  ;  6,  head 
of  the  femur  ;  7,  iliac  bone  ;  8,  iliacus  muscle. 

Fig.  71.  The  "Principal  Plane"  of  Veit,  through  the  Lower  Border 
of  the  Symphysis,  Parallel  with  the  Plane  of  the  Inlet :  1,  the  second 
and  third  sacral  vertebrae;  3,  iliopsoas  muscle;  4,  obturator  internus 
muscle  ;  5,  obturator  fascia  ;  other  numbers  as  in  the  preceding  figure. 

Fig.  72.  Plane  of  Pelvic  Expansion  :  4,  obturator  internus  muscle ; 
9,  pyriformis  muscle.  The  cross  indicates  the  point  of  intersection  of 
the  conjugate  with  the  transverse  diameter,  which  is  situated  much 
farther  forward  than  the  larger  transverse  diameter  of  the  inlet;  the 
latter  plane  was  oval  and  oblique,  this  one  is  oval  and  horizontal. 

forming  the  "  contraction-ring."  Hence,  a  tear  occurring 
in  excessive  contraction  of  the  uterus,  when  there  is 
undue  resistance,  such  as  is  offered  by  a  contracted  inlet, 
begins  at  the  contraction-ring  and  extends  through  the 
^^ lower  uterine  segment,"  where  the  tension  is  greatest, 
as  far  as  the  internal  os. 

The  first  or  dilatation  stage  ends  with  the  complete 
dilatation  of  the  external  os,  allowing  the  head  to  pass. 
A  distention  of  about  4  in.  (10  cm.),  or  the  size  of  the 
palm,  suffices  for  this  purpose.  The  process  is  least  pain- 
ful when  effected  by  the  membranes.  Labor  begins  with 
the  regularly  recurring  contractions  of  the  uterus,  known 
as  labor-pains,  by  which  the  uterus  alternately  hardens 
and  relaxes,  and  with  the  protrusion  of  the  bag  of  waters 
into  the  cervical  canal.  The  latter  consists  principally  of 
elastic  connective  tissue,  the  resistance  of  which  in  the 
process  of  dilatation  is  overcome  partly  by  the  pressure 
of  the  bag  of  waters  and  partly  by  the  contraction 
of  the  longitudinal  fibers  of  the  uterus  and  of  the 
vaginal  fibers  which  extend  into  the  ])ortio  vaginalis. 
Since  the  external  os  lies  in  the  interspinal  line,  it  can  be 
completely  dilated  and  receive  the  head  only  when  the 
largest  diameter  of  the  latter  has  reached  the  plane  of 
expansion,  that  is  to  say,  has  passed  the  inlet.  The  bony 
pelvis  now  begins  to  exert  a  marked  influence  on  the 
movements  of  the  liead. 


Tab.  32. 


Fig    72. 


LUh.Anst  !■:  ReidiJioLd,  Mimchen. 


THE  SECOND   OR  EXPULSIVE  STAGE   OF  LABOR.    85 

g  7.  THE  SECOND  STAGE  (STAGE  OF  EXPULSION)  AND 
THE  RESISTANCE  OFFERED  BY  THE  PELVIC 
PLANES  AND  THE  FLOOR  OF  THE  PELVIS. 

"We  saw  in  s3  that  the  largest  diameters  in  each  of  the 
pelvic  planes  do  not  run  in  the  same  direction.  At  the 
inlet  the  transverse  diameter  is  the  largest ;  when  the 
head,  therefore,  engages  in  the  true  pelvis  its  greatest 
diameter,  the  occipitofrontal,  coincides  with  the  trans- 
verse diameter  of  the  brim  ;  the  sagittal  suture  is  felt  in 
the  transverse  diameter  and,  since  the  latter  lies  nearer 
the  sacrum  (see  Fig.  70),  the  sagittal  suture  in  at  least 
one-third  of  the  cases  is  found  to  be  nearer  the  promon- 
tory. This  is  known  as  NdgeJe's  obliquity,  or  presenta- 
tion of  the  anterior  parietal  bone.  If  the  advancing 
part  is  not  oval  like  the  vertex,  but  more  spherical  like 
the  face  or  the  breech,  the  longest  diameter  is  forced  away 
from  the  promontory  and  coincides  with  the  oblique 
diameter  of  the  inlet ;  the  same  thing  occurs  in  vertex 
presentations  (Solayres  ohliquity)  in  rare  cases  with  com- 
plications. The  size  of  the  inlet  is  further  diminished  by 
the  iliopsoas  muscles,  in  addition  to  the  pelvic  viscera, 
and  the  greatest  transverse  diameter  is  thereby  displaced 
slightly  forward  toward  the  symphysis.  These  muscles 
can  be  relaxed  bv  flexing  and  supporting  the  legs  (Figs. 
60,  61,  70). 

The  second  plane  is  the  plane  of  pelvic  expansion, 
passing  through  the  middle  of  the  third  sacral  vertebra 
and  the  middle  of  the  symphysis  ;  the  oblique  is  its 
largest  diameter,  hence  the  sagittal  suture  rotates  into  it ; 
the  lesser  fontanel  can  usually  be  felt  at  the  anterior  ex- 
tremity of  the  oblique  diameter.  This  is  the  second  rota- 
tion of  the  head ;  the  Jirst  rotation  occurs  when  the 
smallest  or  suboccipitobregmatic  circumference  of  the 
head  descends  into  the  funnel-shaped  pelvis,  and  is  effected 
by  flexion  of  the  head  on  the  chest,  assisted  by  the  uni- 
form contraction  of  the  uterus  and  the  tilting  due  to  the 
pressure  of  the  vertebral  column  on  the  condyles.  The 
oblique  diameter  of  the  plane  of  pelvic  expansion  is  con- 


S6  NORMAL  LABOR. 

Fig.  73.  Skull  of  a  CMld  at  Term  (side  view  ;  from  an  original  photo- 
graph) :  r.-Fr.o.,  straight  or  froiito-occipital  diameter,  corresponding  to 
the  fronto-occipital  distance  or  circumference;  o.mj.  and  o'.mj.,  major 
oblique  diameter,  according  as  the  most  distant  posterior  extremity  cor- 
responds exactly  with  the  lesser  fontanel  or  lies  above  it;  G.L.,  the 
largest  circumference  of  the  head  that  has  to  pass  in  face  presentations 
(the  anterior  extremity  is  the  larynx) ;  o.mi.-s.o.br.,  minor  oblique 
diameter,  corresponds  to  the  suboccipitobregmatic  distance  and  circum- 
ference ;  H.L.,  the  largest  circumference  that  passes  in  occipital  presen- 
tations, does  not  quite  correspond  to  the  suboccipitobregmatic  circum- 
ference;  F.Si.i  and  V.St.,'^  the  two  largest  circumferences  that  pass  in 
brow  presentations,  according  to  the  method  of  delivery.  The  frontal, 
lambdoid,  and  temporal  sutures  and  the  two  temporal  fontanels  are  seen. 

Fig.  74.  The  Same,  Seen  from  Above  (from  an  original  photograph) : 
tr.mj.,  major  transverse  or  biparietal  diameter  ;  tr.mi.,  minor  transverse 
or  bitemporal  diameter.  The  greater  or  anterior  fontanel ;  quadri- 
lateral, formed  by  four  sutures:  the  frontal,  the  two  coronary,  and  the 
sagittal,  which  leads  to  the  lesser,  triangular  or  posterior  fontanel,  and 
joins  the  lambdoid  sutures.  The  radiating  structure  of  the  parietal  and 
frontal  bones  and  their  junction  with  the  parietal  and  frontal  eminences, 
also  the  junction  of  the  occipital  bone  (squama  occipitis)  with  the  occipital 
protuberance,  are  important  from  an  obstetrical  point  of  view. 

siderably  shortened  by  the  pyriform  and  obturator  intern ns 
muscles,  but  is  nevertheless  elastic,  as  the  posterior 
boundary  is  not  formed  by  bone  and  the  anterior  is  partly 
supplied  by  the  obturator  membrane  (Fig.  72). 

There  is  a  certain  developmental  relationship  between  the  size 
of  the  fetal  skull  and  the  maternal  pelvis.  The  size  of  any  indi- 
vidual skull  is,  of  course,  influenced  by  certain  hereditary  factors 
derived  from  parents  and  grandparents,  and  particularly  by  con- 
ditions influencing  the  mother  during  pregnancy  and  the  father 
at  the  time  of  impregnation  (diseases,  nutrition,  etc.).  The  nutri- 
tion of  the  child  bears  a  direct  relation  to  the  size  and  hardness 
of  the  bones  of  the  skull  and  the  smallness  of  the  fontanels,  and 
hence,  also,  to  the  body  weight  and  the  size  and  hardness  of  the 
head.  A  certain  relationship  also  exists  between  the  weight  of 
the  child  and  the  weight  and  age  of  the  mother.  According  to 
the  author's  statistics  mothers  between  the  ages  of  twenty  and 
twenty-nine  years  of  age  and  weighing  over  121  lb.  (55  kgm.), 
especially  multiparse,  produce  relatively  the  heaviest  children, 
and  by  far  the  greater  number  of  them  are  boys.  The  head  of  a 
child  at  term  is  about  six-tenths  the  size  of  the  mother's  in  all 
its  dimensions,  but  it  is  not  a  miniature  of  the  mother's  head. 


Tab.  33. 


Fig.  73 


Fig.  74. 


Liih.Anst  E  Reichhold,  Miincheri. 


THE  SECOND   OR  EXPULSIVE  STAGE  OF  LABOR.    87 

In  multiparte  the  later  children  have  larger  (l  to  -^  in.  =  ^  to  | 
cm.  ill  every  diameter)  and  firmer  heads  than  the  earlier  ones. 

The  skull  of  an  infant  at  term  has  the  following  average  dimen- 
sions: 

Suboccipitohregmatic  circumference,  12f  in.  (32  cm.)  (passes  in 
the  ordinary  occipital  presentations). 

Fronto-occipltal  circumference,  13|  in.  (34  cm.)  (passes  in  occip- 
ital and  brow  presentations). 

Mcntofrontal  circumference,  12f  in.  (32  cm.)  (passes  fiirst  in  face 
presentations). 

Submento-occipital  circumference,  14f  in.  (36f  cm.)  (passes  last  in 
face  presentations). 

Fronto-occipital  diameter,  4f  in.  (12  cm.)  (glabella  to  external 
occipital  protuberance). 

Biparieta I  {major  transverse)  diameier,  S^  in.  (9i  cm.)  (between 
the  two  parietal  eminences). 

Bitemporal  (minor  transverse)  diameter,  S^  in.  (8  cm.)  (between 
the  two  temporal  fontanels). 

Mento-occipntal  (major  oblique)  diameter,  5f  in.  (13J  cm.)  (from 
the  chin  to  the  farthest  point  on  the  occiput). 

Suboccipitobregniatie  (minor  oblique)  diameter,  3|  in.  (9^  cm.) 
(from  the  nape  of  the  neck  to  the  greater  fontanel). 

Vertical  diameter,  3f  in.  (9J  cm.)  (from  the  vertex  to  the  foramen 
magnum). 

During  intra-uterine  life  the  fetal  skull  increases  in  w^idth  and 
the  non-ossified  portions — sutures  and  fontanels — diminish.  As 
early  as  the  fifth  month  the  right  parietal  bone  is  flatter  than  the 
left.  This  phenomenon  depends  on  a  physiological  difference  in 
the  growth  of  the  entire  right  half  of  the  brain,  as  the  author 
has  found  foss?e  and  hemispheres  on  the  left  side  larger  than  on 
the  right  as  early  as  the  fifth  month.  This  observation  is  an  in- 
teresting addition  to  the  chapter  on  "right-handedness."  It  is 
also  interesting  to  note  that  in  the  first  or  commonest  vertex  pre- 
sentation (L.  O.  A.)  the  flattened  right  side  of  the  skull  exactly 
fits  the  outline  of  the  pelvic  inlet,  which  is  normally  somewhat 
flattened  on  the  right  side.  As  the  left  half  of  the  pelvis  is  usu- 
ally somewhat  larger  than  the  right,  that  is,  the  first  or  right 
oblique  diameter  is  the  larger,  so  the  first  vertex  presentation 
(L.  O.  A.)  is  the  most  common.  Whenever  the  oblique  diameters 
were  perfectly  symmetrical,  the  pelvis  was  found  to  be  unusually 
small;  w^hen,  on  the  contrary,  the  left  oblique  diagonal  was  the 
larger,  the  pelvis  was  unusually  large,  especially  in  the  anterior 
transverse  diameter  (iliopubic  distance).  The  second  vertex  pre- 
sentation (back  on  the  right  side,  lesser  fontanel  in  front  and  to 
the  right,  R.  O.  A.),  it  is  true,  is  more  common  when  the  left 
oblique  diameter  is  the  larger,  but,  as  the  entire  pelvis  is  larger, 
this  relation  is  not  so  constant  as  the  contrary  one. 


88  NORMAL  LABOR. 

The  skull  adapts  itself  to  the  shape  of  the  pelvic  canal 
during  labor  by  the  movements  of  its  bones  on  each  other. 
It  is  most  important  to  bear  this  in  mind.  The  greatest 
changes  take  place  in  the  transverse  diameters,  which  are 
diminished  by  twice  the  width  of  the  sagittal,  frontal,  and 
coronary  sutures ;  these  sutures  are  several  millimeters 
wide. 

The  compression  takes  place  in  such  a  way  that  the 
edges  of  the  right  parietal  bone,  which  (in  the  first  vertex 
presentation,  L.  O.  A.)  is  the  deepest  and  most  anterior 
part  of  the  head,  overlap  all  the  others,  while  the  left  frontal 
bone,  which  is  the  most  posterior  part  (toward  the  sacrum), 
is  depressed,  that  is  to  say,  overlapped  by  all  the  adjoin- 
ing bones.  The  left  parietal  and  right  frontal  bones 
occupy  an  intermediate  position  between  these  two.  The 
fontanels  also  play  an  important  role  in  the  compression 
of  the  head.  The  total  diminution  iiT  size  amounts  to 
from  I  to  f  in.  (IJ  to  2  cm.),  especially  if  the  flexibility 
of  the  parietal  bones  is  taken  into  account.  The  posterior 
frontal  bone  becomes  slightly  flattened  by  the  pressure 
of  the  promontory.  As  the  transverse  diameters  are  di- 
minished there  is  a  corresponding  elongation  in  the  sagittal 
direction,  and  here  again  there  is  a  difl^erence  in  the  two 
sides.  Corresponding  to  the  greater  curve  of  the  right 
iliopectineal  line  the  anterior  right  parietal  bone,  in  the 
first  vertex  presentation  (L.  O.  A),  bulges  more  outward, 
while  the  left,  which  is  nearer  the  sacrum,  is  pushed  forward 
toward  the  frontal  bone.  Hence  the  movement  of  the 
two  halves  of  the  skull  on  each  other  is  asymmetrical :  the 
right  half  moving  more  backward,  and  tiie  left  forward. 

The  part  which  is  the  most  advanced  during  labor  is 
drawn  out  to  a  point  and  forms  the  ajiex  of  a  cone,  the 
base  of  which  corresponds  to  that  plane  which  passes  first 
(cf.  the  explanation  of  Fig.  73) ;  thus,  in  the  first  vertex 
presentation  (L.  O.  A.),  the  suboccipitobregmatic  circum- 
ference forms  the  base  of  a  cone,  the  apex  of  which  is  the 
angle  of  the  right  parietal  bone,  which  is  in  contact  with 
the  occipital  bone  and  the  sagittal  suture.     This  explains 


THE  SECOND   OR  EXPULSIVE  STAGE  OF  LABOR.    89 

the  situation  of  the  caput  succedaneum  and  of  cephal- 
hematoma, which  are  caused  by  tlie  pericranium,  together 
with  the  skin,  adhering  to  the  maternal  soft  parts  and 
becoming  se})arated  from  the  skull  during  the  intervals 
between  labor-pains  (Fritsch). 

The  distortions  of  the  head  during  labor  in  vertex 
presentations  consist  not  so  much  in  measurable  changes 
in  the  length  of  the  head,  as  in  a  flattening  of  the  region 
about  the  brow  and  anterior  fontanel,  an  arching  of  the 
presenting  parietal  bone,  and,  in  protracted  labors,  a  more 
vertical  position  of  the  squamous  portion  of  the  occipital 
bone. 

According  to  the  author's  observations  these  deformities  disap- 
pear after  twelve  or,  at  most,  twenty-four  hours.  If  the  deformity 
was  more  serious,  three  to  four  days  were  required.  In  the  case 
of  presentation  of  the  occipital  bone  it  appears  probable  that  the 
deformity  may  persist  for  several  weeks,  and  even  in  a  modified 
form  throughout  the  individual's  life.  In  face,  brow,  and  even  in 
anterior  fontanel  presentations,  the  deformity  is  unquestionably 
permanent  if  there  is  marked  contraction  of  the  birth-canal.  The 
condition  can  be  determined  only  by  making  a  cast  of  the  head ; 
measurements  are  unreliable. 

In  our  discussion  of  the  influence  exerted  by  the  differ- 
ent pelvic  planes  on  the  advancing  head  we  had  reached 
the  plane  of  pelvic  expansion.  As  a  matter  of  fact,  the 
widest  part  of  the  pelvis  is  VeW s  principal  plane  (Fig.  71), 
which  passes  through  the  lower  border  of  the  symphysis, 
parallel  to  the  inlet.  It  forms  a  broad,  almost  circular 
oval,  being  but  little  encroached  upon  laterally  by  the 
iliacus  and  psoas  muscles.  The  anterior  boundary  is  very 
yielding,  being  formed  by  the  broadest  part  of  the  obtu- 
rator membrane  and  a  thin  layer  of  the  obturator  internus 
muscle.  At  this  point  the  head,  which  is  now  entirely 
within  the  cervical  canal,  the  os  being  fully  dilated  (3J  to 
4  in.  =  8  to  10  cm.),  begins  to  rotate  so  that  the  sagittal 
suture  coincides  with  the  oblique  diameter,  Avhile  at  the 
same  time  the  presenting  part  of  the  cranium  (after  the 
membranes  have  ruptured)  begins  to  dilate  first  the  mus- 
cular tissues  of  the  vagina  and  then  the  pelvic  floor.     The 


90  NORMAL  LABOR. 

head  now  comes  in  relation  with  the  pubic  arch,  which  is 
the  least  resistant  portion  of  the  birth-canal  and  plays 
such  an  important  role  in  the  second  rotation  of  the  head 
and  the  passage  of  the  vertical  diameter.  The  head  is 
guided  toward  it  by  the  resistance  offered  to  the  advancing 
parietal  bone  by  the  levatores  ani  muscles  and  the  tissues 
forming  the  pelvic  floor  (Fritsch).  From  above  down- 
ward the  transverse  diameters  of  the  pelvis  progressively 
diminish,  while  the  anteroposterior  diameters  increase. 

After  the  os  is  completely  dilated  the  bag  of  waters 
usually  ruptures  immediately  and  the  head  advances  with 
its  largest  diameter  into  the  dilated  os,  occupying  the  inter- 
spinal line  or  pelvic  strait  of  greatest  pelvic  contraction 
(Fig.  72).    _ 

The  significance  of  this  plane  of  the  pelvis  rests  on  the 
following  considerations  :  1.  Its  conjugate,  which  measures 
4|  in.  (11^  cm.),  is  much  less  extensible  than  is  that  of 
the  outlet,  which  increases  from  4  to  4|^  in.  (10  to  12  cm.), 
owing  to  the  mobility  of  the  coccyx.  2.  It  contains  abso- 
lutely the  shortest  diameter  of  the  entire  pelvis,  the 
interspinal  line.  3.  The  external  os  and  the  advancing 
segment  of  the  head  can  be  palpated  in  this  plane  as  soon 
as  the  largest  diameter  of  the  head  has  entered  the  true 
pelvis  and  the  external  os  is  dilated  to  from  2  to  3^  in. 
(5  to  8  cm.).  This  is  of  the  greatest  diagnostic  import- 
ance, for  it  shows  that  the  largest  diameter  of  the  head 
has  passed  the  inlet.  The  head  is  firmly  wedged  in  the 
pelvis  and  cannot  be  pushed  upward  for  the  purpose  of 
performing  version. 

By  the  expulsive  action  of  the  uterine  contractions 
(labor-pains)  reinforced  by  the  abdominal  muscles,  and  the 
resistance  of  the  coccyx  and  perineum  (see  Fig.  48),  the 
spine  of  the  ischium  acting  as  the  fulcrum,  the  head  now 
rotates  forward  under  the  pubic  arch.  This  rotation  of 
the  sagittal  suture  into  the  conjugate  of  the  outlet,  the 
contraction  of  the  abdominal  muscles,  and  the  bulging  of 
the  perineum  characterize  the  second  stage  or  stage  of 
expulsion  ;  the  head  is  in  the  vagina. 


THE  SECOND   OR  EXPULSIVE  STAGE  OF  LABOR.    91 

From  this  time  expulsion  is  effected  chiefly  by  the 
acticm  of  the  abdominal  muscles;  the  uterine  contractions 
still  continue,  however,  and  excite  the  abdominal  muscles 
reflexly  to  contraction.  The  innervation  is  complicated, 
being  contributed  by  both  the  sympathetic  and  the  spinal 
system. 

The  inferior  strait  consists  reallv  of  two  divero^ing; 
planes  :  the  ''posterior  diaphragm  of  the  pelvis,'^  between 
the  coccyx  and  the  tuberosities  of  the  ischium,  and  the 
"  anterior  diaphragm,"  connecting  the  bones  of  the  pubis 
and  including  the  rima  pudendi.  The  pelvic  outlet 
opposes  but  little  resistance  except  in  funnel-shaped  pelves 
and  in  cases  of  anterior  luxation  of  the  coccyx.  Much 
more  importance,  from  the  obstetrician's  standpoint,  at- 
taches to  the  muscles  between  the  tip  of  the  coccyx,  the 
tuberosities  of  the  ischium,  and  the  lower  border  of  the 
symphysis,  which  make  up  the  pelvic  floor  and  perineum, 
and  form  a  sphincter-like  support  for  the  rectum,  vagina, 
and  urethra. 

The  coccygeus  muscle  passes  from  the  tip  of  the  coccyx  and 
somewhat  Laterally  forward  on  either  side  to  the  tiiherosity  of  the 
ischium.  The  sphincter  ani  also  passes  for^Yard  from  the  coccyx 
to  surround  the  rectum  and  vagina,  making  about  eight  turns,  and 
after  being  reinforced  by  fibers  from  the  transversus  perincei  forms 
the  constrictor  vaginae  and  inserts  into  the  symphyseal  synchon- 
drosis. The  levator  ani  arises  on  the  pubis,  near  the  symphysis, 
and  passes  to  the  spines  of  the  ischium — its  fibers  blending  with 
the  tissues  of  the  vagina,^  which  it  crosses  at  a  right  angle — to  the 
rectum  and  to  the  coccyx  (Figs.  29  and  30).  The  fibers  of  the 
ischiocavernosus  insert  into  the  clitoris.  The  superficial  and  deep 
transversus  perinsei  muscles  lie  in  the  same  plane  and  cover  the 
floor  of  the  pelvis  between  tuberosities  of  the  ischium,  or  the 
adjacent  portions  of  the  ascending  rami  of  the  pubes.  These 
muscles  are,  therefore,  higher,  that  is,  nearer  the  interior  of  the 
pelvis. 

The  interlacing  muscular  bands  form  spaces  which  are  bounded 
by  fascise  or  bands  of  connective  tissue  firmly  adherent  to  the 

1  As  the  connective  tissue  ^vhich  unites  the  fibers  of  the  levator  ani 
with  the  vagina  is  loose,  the  contraction  of  the  muscle  is  not  sufficient  to 
raise  the  vagina,  but  merely  compresses  it  and  carries  it  sli.shtly  nearer 
the  anterior  wall  of  the  pelvis.  When  the  vulva  is  distended  these  muscles 
impart  a  similar  downward  and  forward  movement  to  the  head. 


92  NORMAL  LABOR. 

Fig.  75.  Transverse  Section  of  tlie  Pelvis  at  the  Level  of  the  Internal 
Os  (modified  from  Freund) :  Six  robust  bands  of  connective  tissue 
radiate  forward  (Lg.  v.  u.)  to  the  bladder  (F),  laterally  along  the  base  of 
the  broad  ligaments  {Lg.  I.  d.  et  s.)  to  the  pelvic  wall  {Isch.),  and  back- 
ward {Lg.  r.  u.)  to  the  rectum  {R.)  and  sacrum  («.).  These  bands  are 
accompanied  by  bundles  of  smooth  muscle-fibers.  The  intervals  between 
the  ligamentary  bands  are  occupied  partly  by  loose  connective  tissue 
and  partly  by  the  pelvic  fossse.  Close  to  the  walls  are  found  the  pyri- 
formis  {Py.)  and  obturator  internus  {obt.)  muscles ;  C.  U.,  cervix  uteri ; 
P.,  OS  pubis. 

Fig.  76.  Rupture  of  the  Cervix  and  Vaginal  Fornix,  without  involve- 
ment of  the  external  os,  illustrating  |  6  on  the  attachments  of  the  uterus 
and  of  the  vaginal  vault,  and  their  influence  on  the  direction  of  the 
line  of  rupture  (original  drawing  from  a  preparation  in  the  Munich 
Gynecological  Clinic). 

muscles.  The  subperitoneal  cavity  of  the  pelvis  (deep  perineal 
interspace)  as  far  as  the  pelvic  floor  and  levatores  ani  muscles  is 
filled  with  fat  and  areolar  connective  tissue,  which  communicates 
by  means  of  open  spaces  with  the  ischiorectal  or  subcutaneous 
fossa.  Communication  is  also  established  through  the  great  sciatic 
notch  and  along  the  pyriformis  and  obturator  internus  muscles 
with  the  external  connective  tissue  of  the  pelvis ;  by  means  of 
the  round  ligaments  Vvnth  the  tissues  forming  the  mons  veneris; 
and  by  means  of  the  pubovesico-uterine  ligament  at  the  sides  of 
the  bladder  with  the  abdominal  walls. 

A  knowledge  of  these  anatomical  relations  is  important  not 
only  in  connection  with  the  mechanism  of  labor  and  the  attach- 
ments of  the  pelvic  organs,  but  also  to  explain  the  course  of  sup- 
purative parametritis  and  paravaginal  inflammation  along  the 
line  of  least  resistance. 

Embedded  in  these  masses  of  yielding  tissue  are  the  bladder 
and  urethra,  the  rectum  and  the  vagina.  The  highest  portion  of 
the  latter,  corresponding  to  the  fornix,  derives  additional  support 
from  the  robust  ligaments  which  hold  the  cervix  in  position. 
Lower  down  the  levatores  ani  muscles  embrace  the  vagina,  which 
extends  from  the  external  os  to  the  edge  of  the  hymen.  This  marks 
the  limit  of  the  characteristic  stratified  squamous  epithelium 
which  first  appears  in  the  sixth  month  of  fetal  life;  the  upper 
layer  is  horny,  the  next  succeeding  ones  consist  of  swollen  but 
vigorous  (transitional)  epithelium  in  process  of  transition  from 
the  columnar  to  the  cuboid  variety.  In  the  vaginal  portion  of 
the  cervix  and  in  the  vagina  these  epithelial  cells  in  vertical  sec- 
tion form  a  characteristic  design  of  squares,  lodging  narrow^ 
stroma-papillae  carrying  blood-vessels.  The  individual  cells  are 
connected  by  a  network  of  protoplasmic  threads  and  contain 
large  vacuoles  next  to  the  nuclei.     The  rugae  are  well  developed 


6 


THE  SECOND   OR  EXPULSIVE  STAGE  OF  LABOR.    93 

in  the  virgin.  Glands,  if  they  exist  at  all,  are  represented  by  a 
few  irregular  structures,  the  glandaUe  aberrantes  arvicales  et  vul- 
vares.  Lymph-follicles,  on  the  other  hand,  are  constantly  found 
in  connection  with  the  richly  branching  lymphatic  system.  Foci 
of  round-cell  infiltration  are  frequently  found  and  do  not  neces- 
sarily indicate  the  existence  of  a  local  pathological  affection. 

The  muscular  coat  of  the  vagina  consists  of  unstriped  muscle, 
is  rich  in  veins,  and  is  not  distinctly  separable  into  layers.  It 
contains  both  circular  and  longitudinal  fibers  ;  the  latter  pass 
over  the  fornix  and  merge  into  the  longitudinal  fibers  of  the 
uterus  or  are  reflected  into  the  portio  vaginalis.  The  longitudinal 
fibers  pass  obliquely  from  one  side  of  the  wall  to  the  other  and 
merge  into  the  circular  fibers.  The  vagina  does  not  exert  an 
expulsive  force,  but,  like  the  cervix  and  lower  uterine  segment, 
serves  to  hold  back  the  presenting  part.  The  submucous  layer 
of  connective  tissue  (or  fibrous  tissue)  is  richly  supplied  with 
nerves  and  a  venous  plexus,  and  on  the  anterior  and  posterior 
wall  forms  two  conspicuous  vertical  folds — the  columnce  rugorum. 
The  two  columns©  are  not  placed  exactly  opposite  each  other,  the 
anterior  being  slightly  displaced  to  the  right,  as  a  consequence  of 
the  anterior  displacement  of  the  left  Mlillerian  duct.^  Upon 
these  columns  terminate  the  transverse  folds  which  constitute  the 
excess  of  tissue  designed  for  permitting  the  dilatation  necessitated 
by  labor.  Behind  the  urethral  orifice  is  a  protrusion — the  prom- 
ontoriura  vaginae. 

The  unstriped  muscular  coat  is  supported  by  pelvic  connective 
tissue  and  by  the  muscles  that  have  been  described.  The  pos- 
terior fornix  or  retrocervical  fossa  is  embraced  by  the  fold  known 
as  Douglas'  pouch  (see  Figs.  17,  18,  32).  The  axis  of  the  vagina 
corresponds  with  that  of  the  pelvic  cavity  (from  below  and  in 
front  to  above  and  behind)  and  presents  a  curve  with  its  con- 
cavity looking  forward  and  downward.  The  axis  of  the  non- 
gravid  uterus,  owing  to  its  anterior  inclination,  makes  with  the 
axis  of  the  vagina  an  angle  of  90  degrees  or  less  ;  the  external  os 
rests  on  the  posterior  wall  of  the  vagina. 

During  pregnancy  the  papillary  layer  and.  in  fact,  all  the 
tissues  of  the  mucosa,  undergo  marked  hypertrophy,  the  secre- 
tions are  more  abundant,  and  the  surface  of  the  canal  is  roughened 
and  increased  both  in  length  and  in  width. 

At  the  very  beginning  of  gestation  a  marked  turgescence  of 
the  vulva  is  observed,  which  progressively  increases ;  numerous 

^  Like  the  oviducts,  which  permanently  retain  their  dual  structure, 
the  uterus  and  va.srina  are  at  first  douhle.  developinsfrom  two  Miillerian 
cell-cords,  which  later  become  ducts,  and  finally  fuse  to  form  a  single 
organ.  In  the  columns  described  we  see  the  physiological  remains  of 
this  formation,  while  septa  in  the  uterus  or  vagina  are  pathological 
vestiges  of  it  (uterus  bicornis,  bicoUis,  uterus  duplex,  etc.). 


94  NORMAL  LABOR. 

sinuous  phlebectasiae  are  seen  in  the  mucous  membrane,  and  the 
color  is  dark  and  livid  ;  the  same  appearance  is  noted  in  the 
portio  vaginalis  and  in  the  fornix. 

The  vulva  as  a  whole  takes  both  an  active  and  a  passive  part 
in  the  mechanism  of  labor,  the  one  by  holding  back  the  present- 
ing part  and  forcing  it  toward  the  pubic  arch,  the  other  by  the 
resistance  of  its  sh)wly  yielding,  elastic  tissues. 

A  transitional  structure  is  the  hymen,  or  its  remains,  the 
carunculae  myrtiformes,  which,  to  judge  from  its  position  and  em- 
bryonal origin,  probably  belongs  partly  to  the  vagina  (entoderm) 
and  partly  to  the  vulva  (ectoderm). 

The  urethra  ends  at  the  vestibule,  which  is  bounded  in  front 
by  the  clitoris.  This  consists  of  an  erectile  body,  terminating 
in  front  in  a  glans  and  prepuce,  and  dividing  at  the  posterior 
extremity  into  the  two  diverging  crura  clitoridis,  which  also  con- 
tain erectile  tissue  and  are  attached  to  the  ascending  rami  of 
the  ischium.  The  organ  corresponds  to  a  rudimentary  penis; 
its  base  is  flanked  on  either  side  by  the  cavernous  bulbi  vestibuli. 

The  vestibule  is  bounded  below  and  at  the  sides  by  the  arched 
borders  of  the  nymphse  and  the  frenulum  perinsei  (fourchette). 
The  surface  of  the  former  is  covered  with  numerous  papillae 
covered  with  squamous  epithelium  which  follows  the  inequali- 
ties of  the  surface.  The  papillae  are  wanting  in  the  labia 
majora.  In  adults  sebaceous  follicles  are  found  embedded  in 
both  labia,  in  the  fetus  they  are  absent  from  the  labia  minora. 
The  stroma  of  the  labia  minora  is  rich  in  vessels  and  nerves  (tac- 
tile corpuscles  of  Meissner). 

The  only  organs  in  the  vestibule  covered  with  cylindrical 
epithelium  are  the  glands  of  Bartholin,  whose  ducts  measure 
from  1^  to  If  in.  (3  to  4  cm.)  and  open  about  the  lower  third  of 
the  hymen.  The  perineum  ends  at  the  fourchette  and  consists 
principally  of  the  muscles  described  and  a  thin  layer  of  fat. 

The  above-described  complicated  apparatus  of  soft 
structures,  situated  chiefly  in  the  plane  of  pelvic  contrac- 
tion and  at  the  inferior  strait,  opposes  such  a  resistance 
to  the  advancing  head  as  to  cause  it  to  rotate  forward  and 
upward  (Fig.  48).  Propelled  by  the  labor-pains  and  by 
the  abdominal  pressure,  the  head  stretches  and  compresses 
the  soft  parts  in  a  direction  from  above  and  in  front 
downward  and  backward,  so  that  the  line  joining  the 
fourchette  with  the  lower  border  of  the  symphysis  makes 
a  right  angle  with  the  conjugate  of  the  inferior  strait  (in 
a  non-pregnant  woman  the  angle  is  acute).  The  head, 
after  encountering  the  resistance  of  the  coccyx,  impinges 


THE  SECOND   OR  EXPULSIVE  STAGE  OF  LABOR    95 

on  the  posterior  portion  of  the  perineum,  which  becomes 
greatly  distended  and  elongated.  Thus,  the  lesser  fon- 
tanel is  pushed  under  the  symphysis,  while  the  fibers  of 
the  levator  ani  and  transversus  periucTi  muscles,  which 
are  stretched  to  the  utmost  and  leave  the  anus  gaping 
wide,  retract  over  the  escaping  head.  The  head  now 
performs  the  third  rotation  about  its  transverse  axis,  in- 
creasing the  distance  of  the  chin  from  the  chest,  and  re- 
volves around  the  si/mphi/sis ;  the  lesser  fontanel  first 
appears  at  the  vulva,  then  the  nape  of  the  neck  meets  the 
resistance  of  the  symphysis,  and  finally  the  sinciput,  brow, 
and  face,  in  the  order  named,  escape  over  the  perineum. 

This  rotation  of  the  fetal  head  is  brought  about  by  two 
factors  :  as  the  head  is  subjected  to  a  uniform  pressure  it 
encounters  the  least  resistance  under  the  symphysis,  and 
the  expulsive  force  of  the  abdominal  pressure  acts  upon 
it  less  through  the  yielding  vertebral  column  than  by 
means  of  a  universal  internal  pressure  (reinforced  by 
the  pelvic  resistance)  on  the  trunk,  tending  to  straighten 
the  fetal  body.  The  fetal  spine  itself  assumes  an  obstet- 
rical importance  when,  as  in  face  or  brow  presentations, 
it  occupies  a  position  in  which  it  offers  a  greater  resistance 
to  the  pressure  exerted  from  below  and  behind,  that  is, 
by  the  sacrum.  In  the  ordinary  occipital  ])resentation 
the  head  remains  freely  movable  as  the  pressure  through 
the  vertebral  column  pushes  it  toward  the  sacrococcygeal 
curve,  so  that  a  slight  flexion  suflices  to  allow  it  to  ad- 
vance. In  face  presentations,  on  the  other  hand,  the  ver- 
tebral column  is  alreadv  extended  when  the  head  reaches 
the  sacrococcygeal  curve,  that  is,  the  head  is  flexed  as 
much  as  it  can  be  ;  if  then,  the  chin  is  anterior,  i.  e., 
opposed  to  the  symphysis,  rotation  about  the  symphysis 
may  take  place  by  a  sinking  of  the  chin,  and  the  brow 
escapes  over  the  perineum,  followed  by  the  occiput.  But 
if  the  chin  is  posterior  and  becomes  arrested  in  the  sacral 
curve,  flexion  of  the  head  becomes  impossible  on  account 
of  the  overextension  of  the  vertebral  column,  and  labor 
comes  to  a  standstill. 


96     THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

We  have,  therefore,  to  distinguish  three  different  kind>i 
of  rotation  in  the  birth  of  the  head  in  vertex  presentations: 

1.  Flexion  of  the  head  about  the  transverse  diameter, 
bringing  tlie  chin  nearer  the  breast,  or  descent  of  the  lesser 
fontanel,  to  enable  the  head  to  engage  in  the  superior 
strait — the  result  of  "pressure  on  the  fetal  spine ^'  and 
extension  of  the  trunk. 

2.  Rotation  about  the  vertical  diameter,  anterior  rota- 
tion of  the  lesser  fontanel — the  result  of  the  gradual  in- 
crease of  the  anteroposterior  diameter  as  the  outlet  is 
approached. 

3.  Extension  of  the  head  about  the  transverse  axis, 
arrest  of  the  occiput  by  the  symphysis,  rotation  of  the 
occiput  around  the  syniphysis,  the  effect  of  the  resistance 
offered  by  the  pelvic  floor. 

The  next  step  comprises  the  arrest  of  the  neck  and 
anterior  shoulder  (the  right  in  the  first  vertex  presenta- 
tion, L.  O.  A.)  by  the  symphysis,  and  the  birth  of  the 
anterior  shoulder  under  the  symphysis,  followed  by  the 
escape  of  the  posterior  shoulder  over  the  perineum.  The 
face  then  turns  toward  the  mother's  thigh  (the  right  in 
the  first  vertex  presentation,  L.  O.  A.). 

Similar  movements  of  rotation  are  performed  in  all 
other  straight  presentations  by  the  presenting  part  of  the 
fetus. 

For  further  details  and  for  the  management  of  labor 
the  reader  is  referred  to  the  Atlas  of  Labor  and  Operative 
Obstetrics. 


CHAPTER   IV. 


THE   PUERPERIUM   AND   THE  TREATMENT  OF 
THE  NEW=BORN  INFANT. 

§  8.  PHYSIOLOGY  OF  THE  PUERPERIUM. 

The  puerperium   embraces  the  period   of    retrograde 
changes  in  the  sexual  and  other  organs  affected  during 


PHYSIOLOGY  OF  THE  PUERPERIUM.  97 

pregnancy  (§  2,  table).  Practically  its  duration  is  meas- 
ured by  that  of  the  most  conspicuous  symptom — the 
lochial  discharge.  The  lochia  represent  the  wound-secre- 
tion of  the  lacerated  inner  surface  of  the  uterus,  deprived 
of  its  epithelium  and  of  part  of  the  submucous  connec- 
tive tissue  by  the  separation  of  the  placenta  and  the 
greater  part  of  the  decidua. 

The  separation  and  expulsion  of  the  placenta  usually 
take  place  within  half  an  hour  after  the  birth  of  the 
child  ;  the  process  consists  essentially  in  the  separation 
of  the  fetal  membranes  from  the  uterine  wall.  AVe  have 
seen  (§  1)  that  the  cell-cords  of  the  maternal  decidua  and 
the  fetal  chorionic  villi  are  closely  interwoven ;  hence,  to 
effect  a  clean  separation,  all  the  projecting  processes  of 
one  or  the  other  tissue  must  come  away  bodily  with  the 
bulk  of  the  other  tissue.  As  it  is  the  network  of  chorionic 
villi  that  separate,  the  latter  carry  with  them  all  the  proc- 
esses of  decidual  tissue  that  dip  in  between  the  villi. 
The  maternal  surface  of  the  placenta  is  accordingly  fairly 
smooth,  although  subdivided  by  rather  coarse  furrows 
into  a  number  of  larger  cuboidal  aggregations  of  chorionic 
villi,  known  as  cotyledons  (Figs.  20,  23,  25). 

The  mechanism  of  the  expulsion  of  the  afterbirth  is 
usually  as  follows  :  first,  one  placental  border,  or  a  part 
near  the  border  and  the  central  portion  of  the  placenta, 
or,  rarely,  the  center  alone  is  separated  from  the  uterine 
wall  by  the  muscular  contraction  (Atlas  of  Labor  and 
Operative  Obstetrics,  Figs.  15  and  16).  The  space  thus 
formed  becomes  filled  with  blood  from  the  torn  mater- 
nal vessels  and  the  retroplacental  hematoma  results,  con- 
taining on  the  average  7  fl.  oz.  (225  gm.)  of  blood. 
The  loosened  marginal  portion  is  then  forced  into  the 
internal  os,  the  remainder  of  the  periphery  still  adhering 
(Fig.  27),  whereupon,  in  most  cases,  the  entire  fetal 
surface  with  the  umbilical  cord  is  extruded  into  the 
vagina  and  is,  accordingly,  the  first  portion  to  appear  at 
the  vulva.  This,  which  is  known  as  Schultze's  mode  of 
separation,  does  not,  therefore,  refer  to  the  initial  separa- 
7 


98      THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

tion  of  the  placenta  (Fig.  26).  The  expulsion  of  the 
placenta  is  rarely  effected  throughout  according  to  Dun- 
can's mode,  in  which  the  marginal  portion,  which  is  the 
first  to  separate,  is  also  the  first  to  be  extruded  ;  if  it  does 
so  happen,  the  membranes  are  not  separated  from  the  fetal 
surface. 

After  the  placenta  has  been  extruded  from  the  uterine 
cavity  it  may  remain  indefinitely  in  the  vagina  until  it  is 
finally  expelled  by  the  abdominal  pressure,  by  the 
patient\s  being  cautiously  raised  to  a  sitting  posture,  or 
by  Crede's  method  (Atlas  of  Labor  and  Operaiive  Obstet- 
rics, Fig.  1 8).  If  the  latter  fails  to  effect  its  delivery  it 
is  probably  held  fast  by  a  spasmodic  stricture  of  the 
internal  os  or,  more  rarely,  of  the  constrictor  vaginae,  or, 
in  very  rare  cases,  by  inflammatory  adhesions.  If  the 
uterine  contractions  are  too  weak  to  effect  the  separation 
the  condition  is  usually  accompanied  by  hemorrhage  due 
to  atony  of  the  uterine  muscle. 

When  the  uterine  cavity  is  completely  evacuated  the 
womb  contracts  firmly  and  resumes  its  somewhat  flattened 
shape  ;  the  longitudinal  muscle-bundles  can  be  felt  along 
the  posterior  wall.  The  organ  is  not  spherical,  the  pos- 
terior wall  is  flattened  ;  it  lies  in  anteflexion  and  the  fundus 
reaches  to  about  the  lev^el  of  the  navel.  It  is  only  when 
the  uterus  is  relaxed  that  it  falls  backward  in  retrover- 
sion and  is  covered  by  coils  of  intestine,  or  is  distended 
into  a  globular  form  by  the  inpouring  blood.  These  post- 
partum hemorrhages  from  atony  of  the  uterine  muscle  are 
exceedingly  dangerous,  especially  as  the  woman  in  such 
cases  is  usually  in  a  debilitated  condition. 

The  arrangement  of  the  muscle-fibers  described  in  §  5 
is  such  that  in  contracting  they  constrict  the  traversing 
blood-vessels,  and  effectually  stop  the  flow  of  blood  until 
such  time  as  the  gaping  mouths  of  the  vessels  at  the 
placental  site  are  occluded  by  firm  thrombi.  The  lumen 
of  the  uterus  is  very  narrow  and  is  completely  filled  by 
the  folds  of  mucous  membrane,  the  thrombosed  vessels 
of   the  placental  site,  and    the    lochial    secretion.     The 


PHYSIOLOGY  OF  THE  PUERPERIUM.  99 

cervical  canal  is  reduced  to  a  loose,  flabby  sac  into  which 
the  thickened  folds  of  the  uterine  wall  protrude.  It  is 
most  important  to  be  able  to  recognize  this  condition 
with  the  palpating  finger  in  intra-uterine  manipulations 
during:  the  third  stao;e  of  labor. 

In  regard  to  the  anatomy  of  the  retrograde  changes 
which  take  place  in  the  uterus  during  the  puerperal  period 
more  will  be  said  later  on  ;  for  clinical  purposes  it  is  im- 
portant to  reniember  that,  if  involution  is  normal,  the 
fundus  ought  to  be  found  behind  the  symphysis  on  the 
ninth  day,  and  on  the  fourth  day  nearly  at  the  level  of 
the  umbilicus. 

The  weight  of  the  uterus  on  the  eighth  day  after  parturition  is 
13  to  19  oz.  (400  to  600  gm.)  ;  on  the  fourteenth  day,  10  to  17  oz, 
(300  to  500  gm.)  ;  after  five  weeks,  7  oz.  (200  gm.);  after  eight 
weeks,  2  to  2\  oz.  (50  to  75  gm.).  The  greatest  diminution  ob- 
servable in  the  living  subject  takes  place  from  the  ninth  to  the 
twelfth  day,  when  the  length  decreases  by  1  in.  (2.5  cm.),  the 
breadth  by  f  in.  (2  cm.),  for  each  day;  the  length,  therefore, 
diminishes  more  rapidly  than  does  the  breadth.  The  retrograde 
process  is  one  of  fatty  degeneration,  the  result  of  overgrowth  of 
connective  tissue  in  the  media.  The  albumin  of  the  muscle-cells 
is  converted  into  peptone  (discharged  in  urine  and  lochia;  myo- 
metra).  The  blood-vessels  at  the  placental  site  in  part  become 
occluded  by  thrombi,  in  part  compressed  by  the  contracting 
muscle-fibers.  Pigment  is  found  at  this  site  four  to  six  weeks 
after  parturition.  The  formation  of  new  muscle-fibers  begins 
early.  In  normal  cases  the  decidua  separates  only  in  part.  A 
new  epithelial  covering  is  formed  from  the  epithelium  of  the 
glands.  The  occurrence  of  involution  is  explained  by  the  dimin- 
ished blood  supply  on  account  of  the  contraction  of  the  organ, 
and,  in  part,  is  due  to  the  influence  of  the  nerve-centers. 

Two  causes  are  active  during  the  involution  of  the 
uterus  :  the  permanent  contraction  of  the  organ,  and  fatty 
degeneration  of  the  individual  muscle-fibers.  Both  proc- 
esses are  under  the  control  of  nerve-centers,  hence  any 
undue  mental  excitement  must  be  carefully  guarded 
against,  as  it  might  cause  severe  postpartum  hemorrhage, 
or  arrest  the  flow  of  milk,  or  at  least  produce  chemical 
changes  in  this  secretion.  In  this  connection  I  recall  a 
case  in   which  I  was  summoned  on  the  fourth  day  and 


100   THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

Fig.  77.  Distribution  of  the  Venous  Plexuses  of  the  Pregnant 
Uterus  and  their  relation  to  the  arteries  (modified  from  Heitzmann's 
injected  specimen):  T,  tube  with  fimbriated  extremity;  Lg.l,  broad 
ligament;   f^^  uterus ;  P,  portio  vaginalis  ;   T'^,  vagina. 

Fig.  78.  Distribution  of  the  Lymphatics  of  the  Female  Genitalia 
(after  Poiricr) :  Ut,  uterus;  Ov,  ovarium;  T,  tube;  Lg.r,  round  liga- 
ment ;  Lg.l,  broad  ligament ;  P,  portio  vaginalis  ;  V,  vagina. 

Fig.  79.  Secreting  Cells  of  Mammary  Gland :  1,  fatty  cylindrical 
cells  ;  2,  spindle-cells  in  connective  tissue  ;  .3,  blood-vessel ;  4,  duct.  In 
the  lumen  of  1  are  seen  fat-granules  extruded  by  the  cylindrical  cells 
(original  drawing). 


found  such  an  apparently  unaccountable  hemorrhage,  the 
cause  of  which  proved  to  be  a  dispute  about  the  christen- 
ing of  the  infant,  the  mother-in-law,  who  was  of  a  dif- 
ferent religion,  wishing  to  secure  it  for  her  own  faith. 
In  another  case  the  cause  of  the  hemorrhage  was  the 
burning  of  the  child's  crib.  The  connections  between  the 
genital  ganglia  and  the  central  nervous  system  are  numer- 
ous (see  §  5,  adfinem). 

The  fatty  change  in  the  muscle-cells  can  be  demon- 
strated with  the  microscope ;  the  cells  become  filled  with 
fatty  granules  during  the  puerperium,  later  the  granules 
disappear  and  the  muscle-fibers  are  much  reduced  in  size. 
The  process  is  associated  with  lessened  blood-supply  and 
histological  changes  in  the  vessels  :  diminution  of  the 
lumen  by  overgrowth  of  the  connective  tissue  in  the 
intima  and  fatty  degeneration  of  the  media.  Macroscop- 
ically  the  adnexa,  especially  the  venous  plexuses  and 
Ivmph-channels  of  the  broad  ligaments,  are  seen  to  be 
overfilled  until  tlie  end  of  the  first  week  of  the  puer- 
perium. The  lymph-channels  perhaps  participate  along 
with  the  lochia  in  the  removal  of  the  products  of  de- 
generation in  the  muscle-fibers.  The  slowing  of  the 
pulse,  which  is  physiological,  is  to  be  attributed  to  the 
presence  of  fat  in  the  blood,  while  the  other  product,  pep- 
tone, has  been  found  in  the  urine.  Both  diminished 
pulse-rate  and  peptonuria,  however,  sometimes  occur  in- 
dependently of  involution. 


00 


PHYSIOLOGY  OF  THE  PUERFERIUM.  101 

The  veins  form  plexuses  which,  in  the  main,  follow  the  branches 
of  the  uterine  arteries  and  empty  into  the  internal  iliac  vein. 
The  pampiniform  (or  spermatic)  plexus  lies  in  close  relation  with 
the  tube  and  joins  the  internal  ovarian  vein,  consisting  of  two 
branches  which,  after  uniting,  empty  into  the  renal  vein  on  the 
left  side,  and  directly  into  the  inferior  cava  on  the  right.  If  there 
is  loss  of  vasomotor  tone  or  venous  stasis  the  veins  in  the  broad 
ligaments  form  a  varicocele. 

The  lymphatics  originate  partly  near  the  uterine  glands  and 
partly  in  the  subperitoneal  connective  tissue,  traverse  the  broad 
ligament,  and  terminate  within  the  internal  iliac  and  inferior 
inguinal  glands  of  the  pelvis  and  in  the  inguinal  glands. 

If  the  uterine  cavity  is  invaded  by  pathogenic  germs, 
these  two  channels  furnish  the  paths  by  which  either  the 
toxins  or  the  bacteria  themselves  are  carried  to  other  parts 
of  the  body.  Either  the  thrombi  which  form  in  the 
placental  vessels  become  infected  and  undergo  decomposi- 
tion as  far  as  the  junction  of  these  vessels  with  the  vena 
cava  and  renal  vein,  where  septic  emboli  are  detached, 
enter  the  systemic  circulation  and  become  arrested  in  the 
pulmonary  system,  or  the  germs  make  their  way  through 
the  uterine  walls  along  the  lymph-channels  and,  through 
the  agency  of  the  subserous,  ovarian,  intraligamentary, 
and  other  vessels,  infect  the  surrounding  connective  tissue 
and  the  peritoneum,  giving  rise  to  ijara-  and  perimetritis. 

These  different  forms  of  infection  are  all  included  in 
the  general  term  '^  ptierperal  fever.'' 

The  organism  itself  possesses  efficient  means  of  defence 
to  protect  itself  against  the  invasion  of  such  pathogenic 
germs,  and  an  active  offensive  armor  to  render  them  harm- 
less after  they  have  gained  access  to  the  body. 

The  former  is  found  in  the  anatomical  and  physical 
arrangement  of  the  vulva,  vagina,  and  cervix,  and  in  the 
chemical  properties  of  the  secretion  of  the  vagina  and 
cervix  ;  the  latter  includes  alexins  (antitoxins),  or  bacteri- 
cidal substances  in  the  blood-serum,  and  the  germicidal 
properties  of  the  leukocytes  and  of  the  epithelial  and 
other  cells. 

The  obstetrician  should  not  only  guard  against  the 
entrance  of  bacteria  into  the  genital  tract,  above  all,  the 


102   THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

uterine  cavity,  with  the  greatest  care,  but  should  also  take 
the  proper  precautions  to  preserve  the  efficiency  of  the 
alexins  (antitoxins)  in  the  blood  and  in  the  genital  secre- 
tions. The  integrity  of  the  former  is  preserved  by  keep- 
ing up  the  general  health  of  the  patient,  by  preventing 
the  occurrence  of  hemorrhage  or  fever,  and  by  avoiding  un- 
duly protracted  labor  in  cases  of  contracted  pelvis,  and  by 
removing  as  speedily  as  possible  any  disease  that  may  be 
present  during  pregnancy,  especially  nephritis,  failing 
compensation  in  valvular  lesions,  or  continued  dyspepsia. 

To  guard  against  deterioration  of  the  genital  secretions 
it  is  necessary  to  remove  any  inflammation  of  the  mucous 
membrane,  especially  endometritis,  before  the  onset  of 
labor.  Strong  antiseptic  or  caustic  solutions  should  never 
be  used  sub  partu  to  irrigate  the  vagina ;  in  making  gen- 
ital examinations  care  must  be  had  to  avoid  wounding  the 
tissues  around  the  internal  os ;  the  membranes  must  not 
be  ruptured  too  soon — in  fact,  every  means  must  be  em- 
ployed to  facilitate  the  descent  of  the  presenting  part  as 
much  as  possible,  and  to  obviate  any  cause  for  avoidable 
disturbances  of  the  circulation  in  the  genitalia,  such  as 
allowing  the  head  to  become  wedged  against  the  lateral 
w^alls  of  the  pelvis,  insufficient  or  tardy  rotation,  and 
unskilful  handling  of  the  forceps  in  breech  presentations. 

The  genital  secretion  is  found  in  the  tube,  in  the  uterine 
cavity,  in  the  cervical  canal,  and  in  the  vagina ;  the 
greater  part  of  it  is  produced  in  the  three  first-named 
structures,  that  found  in  the  vagina  mostly  originating  in 
the  cervix.  The  amount  of  secretion  present  in  a  healthy 
virgin  in  all  these  parts  is  exceedingly  small  :  merely  a  little 
mucus  in  the  tubes  and  in  the  uterus ;  and  in  the  vagina 
a  small  quantity  of  dry,  granular  detritus  of  cast-oif 
vaginal  epithelium,  Avhich  becomes  slightly  more  milky 
shortly  before  and  after  menstruation.  Even  in  healthy 
married  women  but  little  secretion  is  found  except  during 
periods  of  congestion,  such  as  menstruation  and  pregnancy. 
The  vaginal  detritus  is  mixed  with  small  quantities  of 
mucus  from  the  cervix ;  the  cervix  itself  is  occupied  by  a 


PHYSIOLOGY  OF  THE  PUERPERIUM.  103 

plug  of  glairv  mucus,  which,  according  to  Kristeller, 
assists  in  fertilizing  the  ovum,  as  it  is  forced  into  the  vault 
of  the  vagina  when  the  orgasm  is  at  its  height,  and  after 
being  loaded  with  spermatozoa  is  drawn  back  into  the 
cervix  by  virtue  of  its  viscidity. 

Examinations  of  mucus  from  healthy  tubes  and  from 
the  uterine  cavity  show  that  it  is  sterile,  i.  e.,  free  from 
pathogenic  germs.  The  same  is  true,  in  most  cases,  of  the 
upper  two-thirds  of  the  cervical  canal,  which  is  closed  by 
a  plug  of  tough,  glairy  mucus,  preventing  the  entrance 
of  bacteria  (Ahlfeld)  and  covered  near  the  external  os  by 
a  layer  containing  leukocytes.  The  latter  are  undoubtedly, 
as  Walthard  has  pointed  out,  placed  there  to  stand  guard 
at  the  entrance  of  the  uterine  cavity,  since  immediately 
below  them,  in  the  external  os,  a  narrow  zone  containing 
large  numbers  of  bacteria  can  be  demonstrated.  The 
vagina  soon  after  birth  becomes  the  abiding-place  of 
numerous  germs,  which  grow  more  and  more  plentiful  as 
the  introitus  is  approached.  Some  of  these  germs  are 
pathogenic,  although  in  healthy  individuals  with  normal 
genitalia  their  virulence  is  very  slight  (Walthard,  Ahlfeld, 
Vahle,  Kottmann).  Still,  they  are  unquestionably  there, 
and  any  complication  during  labor  may  alter  the  conditions 
of  their  surroundings  so  as  to  increase  their  virulence  and 
lead  to  the  infection  of  the  uterine  cavity  (thrombosis  of 
the  uteroplacental  vessels)  or  of  any  other  solution  of 
continuity  in  the  mucosa  of  the  genital  tract ;  in  other 
words,  may  set  up  puerperal  fever.  Such  altered  condi- 
tions include,  for  instance,  lacerations  and  the  presence  of 
putrescible  organic  matter  (dead  fetus,  contused  tissues). 
Another  favorable  medium  for  the  growth  of  bacteria  is 
furnished  by  the  gonococcus,  which  in  itself  is  also  capa- 
ble of  producing  puerperal  febrile  conditions.  But  by  far 
the  most  frequent  and,  from  a  practical  standpoint,  the 
only  source  of  infection  worth  considering  is  lack  of 
cleanliness  in  digital  explorations.  The  dangers  from  this 
source  increase  in  direct  proportion  to  the  duration  of 
labor,  the  presence  of  complications,  and  the  favorable 


104    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

Fig.  80,  Mammary  Gland  of  a  Blonde  Primigravida,  in  the  Seventh 
Month  (original  water-color). — Striae  ;  turgesceuce  of  the  nipple  and  of 
the  entire  breast,  which  does  not  hang  down  ;  moderate  pigmentation 
of  areola  ;  so-called  "milk-veins"  seen  through  the  integument. 

Fig.  81.  Necrotic  Decidua  (see  §  12). 

condition  of  the  soil  for  pathogenic  germs.  All  the 
bacteria  which  have  their  habitat  about  the  external  geni- 
talia have  been  found  within  the  vagina ;  they  include  the 
Streptoco(;cus  pyogenes  (a  non-pathogenic  streptococcus  is 
also  found),  Staphylococcus  albus  and  aureus,  Bacterium 
coli  commune,  occasionally  Frankel's  pneumococcus,  which 
is  found  even  in  pyosalpinx,  and  Loffler's  diphtheria 
bacillus  (another  non-specific  bacillus  resembling  the  latter 
has  also  been  found).  In  addition  to  these  there  is  pres- 
ent as  a  constant  inhabitant  Doderlein's  bacillus,  the  thick, 
rod-shaped  organism  to  which  the  bactericidal  acid  reac- 
tion of  the  vaginal  mucus  is  attributed,  though  it  is  not 
always  bactericidal,  and,  finally,  large  numbers  of  so-called 
anaerobic  saprophytes,  which  cause  the  putrefaction  of 
retained  shreds  of  ovum.  It  is  important  to  remember 
that  the  bactericidal  power  of  the  genital  secretions  is 
much  diminished  or  even  destroyed  during  the  first  days 
of  the  puerperium,  owing  to  their  conversion  into  the 
alkaline  lochial  discharges.  During  labor,  on  the  other 
hand,  their  bactericidal  power  is  greatly  reinforced  by  the 
presence  of  the  amniotic  fluid,  which  possesses  the  same 
property  in  a  marked  degree.  Experiments  with  this 
fluid  have  shown  tliat  so-called  anaerobic  saprophytes 
cannot  live  in  it  at  all,  and  even  the  pathogenic  varieties 
lose  their  virulence. 

Kronig,  with  other  authors,  denies  the  presence  of 
pathogenic  germs  (streptococci)  in  the  healthy  vaginal 
secretion  of  a  pregnant  woman. 

The  lochia  are  divided  into  three  physiological  forms : 
lochia  cruenta  (rubra),  consisting  of  blood  only  ;  lochia 
serosa,  consisting  of  serum  with  numerous  leukocytes, 
nucleated  decidual  cells,  epithelial  cells,  and  cocci ;  and 
lochia  alba,  serum  with  but  few  cells  and  cocci : 


00 


o 


PHYSIOLOGY  OF  THE  PUERPERIUM. 


105 


Days. 
1st  to  2d. 


2d  to  3d. 


:3d  to  5th. 


7th  to  8th. 


9th. 


10th. 


Mother. 

Lochia  cruenfa  or  rubra.  Fun- 
dus almost  at  the  umbili- 
cus ;    afterpains.     Liquid 
diet. 
{Lochia  cruenta.  congestion 
of  breast.     Lateral  de- 
j      cubitus  permissible. 
Lochia     serosa,     tempera- 
ture :  98.6°  to  100.4°  F. 
(37°  to  38°  C.)  maximum. 
Lochia  alba,   colostrum    has 
disappeared  ;        placental 
site  can  still  be  felt. 
Fundus    behind    the    sym- 
physis. 

Patient  may  be  allowed  to 
get  up. 


Child. 

Line  of  demarcation  appears 
on  the  navel.  Greatest 
diminution  in  weight. 

Separation  of  cord  ;  mecon- 
ium has  disappeared. 


Physiological  jaundice. 


Temperature  :  98.4°  to  100° 
F.  (36.8°  to  37.7°  C). 
Weight  same  as  at  birth. 

Average  daily  gain,  20  to  35 
grammes. 


There  is  a  physiological  connection  between  the  lochial 
discharge  and  the  secretion  of  milk,  the  latter  beginning 
on  the  second  to  the  fourth  day,  when  the  former  under- 
goes a  change.  Conversely,  an  excessive  lochial  discharge 
influences  the  amount  of  milk  secretion  unfavorably. 
Massage  of  the  abdominal  walls  and  viscera  has  a  favor- 
able effect  on  both  the  lochial  discharge  and  the  secretion 
of  milk. 

The  involution  of  the  muscularis  has  been  mentioned 
in  §  5.  The  regeneration  of  the  mucous  membrane  is 
marked  by  the  gradual  destruction  of  the  decidual  cells 
and  the  growth  of  a  stroma  rich  in  round  cells,  in  which 
and  from  which  the  new  glands  are  formed.  The 
regeneration  of  the  latter  is  accomplished  by  proliferation 
of  the  intact  cylindrical  cells  in  the  fundi  of  the  glands. 
These  cells  also  produce  the  single  layer  of  cylindrical 
cells  which  clothes  the  surface  of  the  newly  formed 
mucous  membrane  (see  Fig.  87). 

The  involution  of  the  other  organs  of  the  body  was 
referred  to  in  §  2.  For  clinical  purposes  it  is  to  be  re- 
membered that  the  pulse  of  a  puerperal  patient  is  often 
exceedingly  slow  and  soft,  hence  the  presence  of  even  a 
moderately  accelerated  pulse  should  excite  suspicion, 
though  a  certain  degree  of  irregularity  is  physiological  in 


106   THE  PUERPERWM  AND  NEW-BORN  INFANT. 

Fig.  82.  Lochia  Rubra  or  Cruenta :  1,  decidual  cells ;  2,  squamous 
epithelium;  3,  red  blood-corpuscles  iu  rouleaux;  4,  isolated  red  blood- 
corpuscles;  5,  leukocytes;  6,  isolated  cocci  (diplo-). 

Fig.  83.  LocMa  Serosa  or  Sanguinolenta  (numbers  the  same  as  in  the 
preceding  figure).— The  cells  are  granular. 

Fig.  84.  Lochia  Alba :  6,  masses  of  cocci ;  7,  granular,  vesicular 
spindle-cells  ;  8,  cholesterin  plates. 

Figs.  82-84. — Drawings  from  original  preparations. 

Fig.  85.  Colostrum-cells.— Fat-droplets  (1)  extruded  (3)  from  the 
fatty  cells  (4)  (cf.  Fig.  79) ;  2,  leukocytes. 

Fig.  86.  Milk.— The  fat-droplets  (1)  are  suspended  in  water ;  two  leuko- 
cytes are  seen  (2). 

Figs.  85  and  86.— Drawings  from  original  preparations. 

Fig.  87.  Section  through  the  Wall  of  a  Puerperal  Uterus  (microscop- 
ical ;  original) :  1  and  2,  circular  muscle-fibers,  some  of  them  in  a  state  of 
granular  degeneration ;  4,  loose-meshed,  edematous  connective  tissue ;  3, 
large  muscle-fibers  in  cross-section  ;  5,  a  large,  thick-walled  vessel  with 
red  thrombus  and  beginning  fibrin  formation  ("  ribbed  ") ;  6,  a  vessel  in 
which  the  thrombus  has  become  completely  organized,  showing  lamella 
formation  ;  9,  large  capillary  vessels  of  the  subdecidual  mucosa  already 
converted  into  connective  tissue  ;  7,  irregularly  contracted  muscle-fibers 
in  process  of  degeneration,  the  cells  have  failed  to  take  the  stain ;  8,  large 
capillary  vessels  newly  formed  during  pregnancy  ;  10,  glandswhich  have 
retained  their  cylindrical  epithelium  in  the  depth  during  pregnancy; 
these  cells  subsequently  proliferate  and  furnish  a  covering  for  the  regen- 
erating mucous  membrane ;  11,  stroma  of  the  mucous  membrane  contain- 
ing numerous  decidual  cells  (12,  13)  ;  in  one  of  the  capillary  spaces  filled 
with  decidual  cells  is  seen  a  chorionic  villus  (14). 

the  beginning  of  the  puerperal  period.  Individual 
idiosyncrasy  plays  a  much  more  important  role  in  this 
slowing  of  the  pulse-rate  than  the  earlier  authors  were 
disposed  to  admit  (Heil). 

As  the  lochial  discharges  diminish,  the  changes  in  the 
mammary  gland  culminate  in  the  establishment  of  its 
true  function,  the  copious  secretion  of  milk  (on  the  third 
day). 

As  early  as  the  second  month,  as  has  been  mentioned 
in  §  2,  it  is  often  possible  to  express  serum  from  the 
nipple.  The  first  indications  of  the  changes  brought 
about  by  pregnancy  are  observed  during  the  first  month 
in  the  form  of  tugging  and  stabbing  pains,  a  feeling  of 
increased  weight  and  distention,  tenderness  on  pressure, 


Tab.  37. 


•(-...-'^'^W'Q'O   ®\' 


fe^SS?^^ 


a 


^■OQ 


?■  t>(?P'^'e0 


^i4 


/    r 


Fig.  82. 


S-^, 


:.      ^ 


®'Bmck:^'P^k-o'& 


-bVQ' 


Fig.  83. 


Fig.  84. 


2  S 


cO^ 


«> 


O 


o 


C  J  .^ 

O  "       1 


Fig.  85 


Fig.  86. 


'-4^^ 
^ 


— .y 


y^- 


Fig.  87. 


Lith.Anst  F  Reichhold,Mujichjen. 


PHYSIOLOGY  OF  THE  PUERPERIUM.  107 

and  the  presence  of  radiating  cords  recognized  by  the 
sense  of  touch.  The  fifth  month  is  characterized  by  the 
appearance  of  stri.T,  pigmentation  of  the  areola,  the 
formation  of  a  secondary  areola,  and  l)y  prominence  of 
the  Malpighian  glands.  The  epithelium  of  the  acini 
proliferates  and  forms  new  glandular  structures,  while 
the  interlobular  connective  tissue  swells  and  becomes 
looser ;  fat  begins  to  form  in  the  interstices  between  the 
fifteen  to  twenty-four  cake-like  lobes  of  each  gland,  the 
ultimate  lobides  of  which  correspond  to  the  above-men- 
tioned glandular  acini.  The  ducts  of  the  individual  lobes 
unite  at  the  nipple  and  together  form  the  lactiferous  sinus. 

The  cells  of  the  glandular  epithelium  are  polyhedral,  somewhat 
flattened,  and  granular  ;  they  are  separated  from  the  lymph- 
channels  by  a  small  amount  of  connective  tissue,  which  cor- 
responds to  the  tunica  propria,  and  a  layer  of  endothelial  cells 
outside  of  the  latter. 

During  pregnancy  the  cells  become  taller,  more  cuboidal,  mul- 
tinuclear,  and  contain  more  albumin;  fat-droplets  collect  in  their 
free  border  near  the  lumen  of  the  acinus,  and  are  discharged 
along  with  the  peripheral  portion  of  the  cell  (Fig.  79). 

We  find  such  alveolar  cells  filled  w4th  fat-granules  in  the 
colostrum,  where  they  constitute  the  colosf rum-corpuscles  (Fig. 
85).  They  are  found  in  the  milk  until  the  fifth  day  of  the  puer- 
perium,  and  by  their  rupture  the  suspension  of  the  fat-droplets 
in  the  milk-serum  is  accomplished  ;  the  process  begins  in  the 
milk  of  the  third  and  fourth  days  (Fig.  86).  The  delicate  so- 
called  '*'  haptoofenic  membrane  "  of  the  milk-globules  has  no  actual 
existence.  Milk  is  a  simple  emulsion  of  fat-droplets.  Leukocytes, 
isolated  pale  cells,  and  fission-fungi  (staphylococci;  are  also  found 
in  milk. 

Composition  of  Human  Milk  : 


Xeic. 

Old. 

(Fifth  day  after  delivery.) 

iFiv 

6  months  after  delivery.) 

1.52                                   0.9 

3.92  casein. 

3.28                                   3.3 

3.66  fat. 

5.38                                   6.8 

4.36  susar  of  milk. 

0.30                                   0.2 

O.U  salts. 

2.-5 

0.38  albumin. 
0.13-0.33  peptone. 

In  addition  the  milk  contains  urea,  lecithin,  and  cholesterin. 
Dailv  quantity  1  to  3  pints  (500  to  1500  c.c.) ;  specific  gravity  1026 
to  1036. 


108    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

Colostrum  contains  principally  albumin,  which  is  converted 
into  casein  in  the  milk  and  is  coagulated  as  such  by  boiling  or 
precipitated  by  rennet :  it  also  contains  salts — magnesia,  calcium 
phosphate,  common  salt,  and  chlorine — which  act  as  laxatives  to 
assist  in  the  evacuation  of  meconium. 


I  9.  PHYSIOLOGY  AND  FEEDING  OF  THE   NEW=BORN 

INFANT. 

The  natural  and  only  ^'  ideal  '^  food  for  the  nursling 
is  its  mother's  milk,  providing  the  mother  be  well  and 
strong,  and  neither  markedly  neurasthenic  nor  hysterical. 
It  is  better  than  the  milk  of  a  wetnurse  for  several  rea- 
sons :  in  the  first  place,  the  time  of  delivery  is  rarely  the 
same  in  the  wetnurse  as  in  the  mother,  and  the  chemical 
concentration  of  the  milk  is  thereby  materially  affected ; 
in  the  second  place,  one  can  never  be  sure  of  the  consti- 
tution, past  history,  and  general  character  of  the  wet- 
nurse  ;  and,  in  the  third  place,  it  cannot  be  doubted, 
although  the  question  is  not  susceptible  of  proof,  that  the 
milk  of  its  own  mother,  providing  she  be  healthy,  is 
always  the  one  best  adapted  to  the  infant's  needs.  Chil- 
dren brought  up  on  their  own  mother's  milk  not  only 
appear  to  thrive  better,  but  show  a  greater  power  of  re- 
sistance, both  during  infancy  and  in  later  life.  In  other 
words,  they  acquire  a  more  vigorous  constitution. 

The  best  criterion  of  an  infant's  well-being  is  its  gen- 
eral habit  and,  above  all,  its  body  weight.  The  new-born 
infant  for  some  time  after  birth  must  be  regarded  as  a 
relatively  immature  creature,  especially  as  compared  with 
the  young  of  most  mammals.  Its  volitional  acts  during 
the  first  weeks  of  life  are  exclusively  limited  to  the  regu- 
lation and  performance  of  vegetative  functions.  Thus 
the  separate  organs  of  the  body,  as  they  gradually  ap- 
proach a  state  of  independence,  acquire  the  necessary  tone 
and  power  of  resistance  to  enable  them  to  withstand  del- 
eterious influences  from  without.  Hence  the  index  of  the 
infant's  growth  is  found  not  only  in  the  increase  of  the 
body  weight  itself  in  proportion  to  its  growth  and  its  in- 


PHYSIOLOGY  AND  FEEDING  OF  NEW-BORN  INFANT.  109 

crease  in  size,  but  particularly  in  the  increased  density 
of  the  individual  organs  by  the  deposition  of  the  essential 
tissue-elements  on  which  their  functions  depend.  Since, 
however,  all  the  "  vegetative^'  organs,  with  the  exception  of 
the  lungs, are  activeduringthe  last  monthsof  fetal  life  (heart 
and  vascular  system,  liver  and  bile  secretion,  renal  and 
even  gastric  and  intestinal  secretion ;  the  fetus  even  per- 
forms the  act  of  deglutition,  as  shown  by  the  lanugo 
hairs  which  find  their  way  into  the  intestine  along  with 
the  amniotic  fluid),  they  are  found  to  have  reached  a  cer- 
tain stage  of  development  in  the  new-born,  so  that  the 
important  process  of  nutrition  and  digestion  can  begin  at 
once. 

The  brain  at  birth  possesses  relatively  the  lowest  specific 
gravity  of  any  of  the  organs. 

As  regards  the  morphology,  the  formation  of  the  first  fissures  is 
not  observed  until  the  seventh  or  eighth  fetal  month ;  at  birth 
the  convolutions  are  already  fairly  well  developed.  The  tissue- 
elements,  however,  and  the  chemical  composition  are  in  a  very 
undeveloped  state.  Although  the  brain  appears  to  keep  pace  with 
the  other  organs  and  with  the  entire  body  in  regard  to  bulk  after 
the  fourth  fetal  month,  its  weight  is  relatively  much  lower,  the 
specific  gravity  being  even  less  than  that  of  the  blood,  hence  the 
brain  of  a  new-born  infant  contains  a  greater  percentage  of  water 
than  does  its  blood.  This  condition,  however,  undergoes  a  rapid 
change  during  the  first  year  of  life,  the  specific  gravity  of  the 
brain  increasing  as  the  psychical  functions  are  awakened. 

Like  the  cerebral  functions,  volitional  movement  of 
the  muscles  of  the  limbs  and  trunk  remain  in  abeyance 
during  intra-uterine  life.  The  so-called  ^' fetal  move- 
ments,''  which  are  felt  after  the  fourth  fetal  month,  both 
by  the  mother  and  by  the  hand  of  the  examiner,  represent 
merely  reflex  movements  and  are  in  no  sense  purposeful. 
Although  they  appear  to  be  quite  forcible,  the  amount 
of  muscular  exertion  is  reallv  very  sbVht,  as  the  amniotic 
fluid  in  which  the  child  is  suspended  is  quite  high  in 
specific  gravity  and,  therefore,  permits  the  trunk  and  limbs 
to  be  moved  with  very  little  exertion. 

The  histological  changes  which  occur  in  the  first  days  of  life, 
as  muscular  activity  begins  to  be  established,   are  such   as  we 


no   THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

should  expect  to  find.  The  muscles  of  the  fetus  and  of  the  new- 
born infant  are  pale  in  color  and  very  quickly  become  fatigued 
after  electrical  stimulation.  In  other  words,  they  go  into  fatigue- 
cramp,  and  this  probably  explains  why  the  new-born  infant  is  so 
subject  to  convulsions;  if  we  make  a  tracing  of  the  muscular  con- 
tractions in  new-born  infants,  we  find  that  the  curves  resemble 
those  of  fatigued  muscles  in  an  adult.  Under  the  microscope 
these  pale  muscles  present  only  transverse  striations  ;  whereas, 
the  muscles  of  children  five  to  eight  days  old  are  not  only  of  a 
deeper  red  color  but  also  show  both  longitudinal  and  transverse 
striations  very  plainly. 

The  rapidity  with  which  calcium  salts  are  deposited  in 
the  skeleton  may  be  judged  by  the  speedy  hardening  of 
the  bones  of  the  skull,  which  at  birth  are  still  quite  com- 
pressible, and  by  the  rapid  closure  of  the  sutures  and  fon- 
tanels, in  spite  of  the  active  growth  of  the  brain  and 
calvarium.  If  the  food  contains  an  insufficient  amount 
of  calcium  salts,  rachitic  softening  of  the  bones  results, 
or  at  least  the  closing  of  the  fontanels  is  delayed  beyond 
the  first  year,  giving  rise  to  parchment-like  crepitation 
of  the  flexible  and  movable  cranial  bones. 

This  consolidation  of  the  tissues  is  the  sole  occupation 
of  the  new-born  infant  during  the  first  weeks  of  its  life. 

The  establishment  of  the  sense  of  sight  is  the  first  sign,  as  it  is 
the  principal  factor  in  the  awakening  of  the  psychical  life.  The 
time  of  its  appearance  is  subject  to  variation,  depending  on  indi- 
vidual development  and  particularly  on  the  general  bodily  health. 
Thus  the  baby  will  begin  to  stare  at  a  conspicuous  object  in  its 
second  month,  although  reaction  to  a  bright  light  is  established 
very  soon  after  birth,  and  there  is  an  evident  appreciation  of  loud 
sounds  and  of  the  taste  of  very  irritating  substances,  such  as  qui- 
nine. During  the  third  and  fourth  months  the  infant  begins  to 
appreciate  finer  differences  by  the  sense  of  sight,  and  in  the  sixth 
month  by  the  sense  of  hearing.  The  tactile  sense  is  strongly 
developed  from  the  beginning,  especially  about  the  mouth. 

In  debilitated,  sickly,  or  insufficiently  nourished  children,  the 
awakening  of  conscious  sensations,  of  perceptions  by  the  special 
senses,  of  conscious  imagination,  and,  finally,  of  conscious  mem- 
ory, is  delayed  until  a  later  period. 

At  the  moment  of  birth  a  profound  revolution  takes 
place  in  all  the  organs.  Whereas,  up  to  this  period,  the 
purification  of  the  infant's  blood,  the  process  of  supplying 


PHYSIOLOGY  AND  FEEDING  OF  NEW-BORN  INFANT.  Ill 

it  witli  matured  products  of  metabolism,  and  the  function 
of  respiration  (rece})tion  of  oxygen,  as  well  as  elimina- 
tion of  carbon  dioxide)  is  performed  exclusively  by  the 
mother,  and  even  the  infantile  circulation  is  materially 
assisted  by  the  uterine  tonus  which  reacts  on  the  vessels 
of  the  chorionic  villi — from  the  moment  of  birth  the 
childish  or2:anism  is  thrown  entirelv  on  its  own  resources. 
Not  only  is  the  heart  called  upon  to  do  its  work  alone, 
but  this  work  is  materially  increased  by  the  fact  that,  as 
pulmonary  respiration  begins,  the  entire  mass  of  blood 
has  to  be  forced  through  the  intricate  system  of  pulmonary 
capillaries,  where  the  altered  blood-current  encounters  a 
new  and  considerable  resistance. 

At  each  inspiration  (which  at  first  is  of  little  importance  in 
respect  to  respiration)  the  lungs  take  up  large  quantities  of  blood 
into  the  capillaries  of  the  pulmonary  arteries,  which  now  contain 
blood  from  the  right  ventricle  instead  of  carrying  it  directly  to 
the  aorta  through  the  ductus  arteriosus.  The  ductus  arteriosus 
is  therefore  superfluous  and  becomes  obliterated  about  the  end  of 
the  third  month.  The  pulmonary  veins  convey  the  first  oxygen- 
ated blood  back  into  the  left  auricle  of  the  heart;  this  produces 
a  rise  in  pressure  which  prevents  the  entrance  of  mixed  blood 
from  the  right  auricle;  all  the  blood  goes  into  the  right  chamber 
and  from  there  into  the  pulmonary  arteries,  and  the  lesser  circu- 
lation is  established,  closure  of  the  valve  of  the  foramen  ovale 
begins  and  is  completed  in  from  sixty  to  eighty  days.  The  fetal 
circulation  has  become  converted  into  the  infantile  circulation. 

As  has  been  mentioned,  the  digestive  organs  of  the 
new-born  infant  secrete  small  quantities  of  ferments  capa- 
ble of  decomposing  both  starch  and  albumin  ;  hence,  we 
have  a  scientific  proof  of  the  possibility  of  digesting 
starches,  which  is  an  important  point  in  artificial  feeding. 
Human  milk  is  so  accurately  adapted  to  the  needs  and  to 
the  chemical  powers  of  assimilation  of  the  stomach  and 
intestine  that  only  very  healthy  human  infants  can  digest 
unprepared  cows'  milk.  Cows'  milk  contains  much  more 
casein  than  does  human  milk  ;  the  amount  of  pepsin  con- 
tained in  the  human  stomach  is  not  sufficient  to  digest  this 
casein  and  render  it  fluid,  hence  the  casein  does  not  get 
beyond  the  stage  of  coagulation  in  the  acid  gastric  secre- 


112    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

tion,  and  passes  into  the  intestinal  canal  in  the  form  of 
curds,  which  are  frequently  vomited.  These  solid  particles 
irritate  the  mucous  membrane  and  form  a  favorable  medium 
for  the  development  of  any  pathogenic  micro-organisms 
that  may  have  entered  with  the  food. 

Asses^  milk  or  goats'  milk  is  best  adapted  to  the  human 
infant,  but  it  is  difficult  to  obtain. 

But  although  the  milk  of  animals  may  be  harmful,  it 
may  be  preferable  to  the  mother's  milk  if  the  quality  of 
the  latter  has  deteriorated  by  reason  of  the  mother's  ill 
health  or  a  sudden  nervous  disturbance,  such  as  fright, 
anger,  or  convulsions.  Under  these  conditions  the  milk 
may  make  the  child  vomit  or  set  up  a  diarrhea,  with 
attacks  of  colic  or  even  general  convulsions. 

It  is,  of  course,  evident  that  the  infant  must  possess 
some  natural  means  of  protection  against  such  accidents ; 
they  are,  however,  subject  to  great  individual  variations. 
They  depend  on  the  inherited  fetal  energy,  the  congenital 
power  of  resistance,  in  short,  that  which  is  known  as 
'^  constitution."  The  simplest  and  most  reliable  means  of 
determining  this  resisting-power  consists  in  weighing  the 
child  regularly  every  week.  The  factors  which  determine 
the  body  weight  and  power  of  resistance  of  the  infant 
during  the  first  months  of  life  are  somewhat  complex. 

It  has  been  said  that  the  period  at  which  ihe  special  senses  first 
make  themselves  manifest  in  infants  depends  on  the  individual 
progress  in  the  development  of  the  entire  body,  which  again  is 
influenced  by  the  inherited  constitution  and  the  care  and  feeding 
of  the  infant,  and  that  the  first  weeks  of  life  are  entirely  devoted 
to  building  up  the  resisting  power  of  the  whole  organism,  so  as  to 
enable  it  to  withstand  the  transition  from  fetal  to  independent 
metabolism.  The  body  weight  is  not  only  an  index  of  the  infant's 
growth  and  general  development,  but  it  also  furnishes  us  with  the 
means  of  determining  any  arrest  of  development  due  to  some 
obscure  lesion,  the  cause  of  which  may  not  necessarily  reside  in 
the  child  or  in  its  food  or  even  in  the  constitution  of  the  parents, 
but  may  be  a  temporary  injury  to  the  mother  during  pregnancy 
or  at  the  time  of  conception,  such  as  illness,  mental  trouble,  alco- 
holic abuse.  Thus  the  latent  stage  of  a  disease  may  be  revealed 
by  a  sudden  fall  in  the  body  weight  before  any  symptoms  become 
manifest. 


PHYSIOLOG  Y  AND  FEEDING  OF  NEW-BORN  INFANT.  1 1 3 

If  we  take  a  series  of  healthy  children  born  of  healthy 
parents  and  examine  the  changes  in  weight,  from  the  first 
days  of  life,  we  find  that  the  body  weight  undergoes  typi- 
cal variations,  and  if  we  represent  these  variations  by  a 
curve  we  find  a  marked  decline  immediately  after  birth, 
the  lowest  point  being  reached  on  the  third  day  of  the 
infant's  life.  From  this  point  the  curve  gradually  rises; 
but,  according  to  my  investigations,  not  more  than  14  per 
cent,  of  all  the  children  regain  their  original  weight  by 
the  end  of  the  first  week ;  many  do  not  reach  this  point 
before  the  seventh  or  even  the  tenth  day,  while  in  44  per 
cent,  the  weio:ht  at  the  end  of  the  second  week  is  still 
lower  than  it  was  at  birth. 

The  cause  of  this  loss  of  weight  is  to  be  sought  in  the 
metabolic  processes.  I  compared  the  absolute  weight  of 
the  ingested  milk  with  the  total  amount  of  intestinal  and 
renal  excretion,  to  which  I  added  the  liquid  and  gaseous 
and  metabolic  products  excreted  through  the  skin  and 
lungs,  with  the  following  result :  ^ 

From  the  first  to  the  third  day  (inclusive)  : 
10  oz.  (+  300  gm.)  ingested  milk. 
15  oz.  (—453  gm.)  excreted  products  of  metabolism. 
5  oz.  (—  153  gm.). 

Five  ounces  (153  gm.),  therefore,  represents  the  apparent  loss  in 
body  weight.  As  a  matter  of  fact,  however,  ihe  average  loss  dur- 
ing these  three  days  amounts  to  11  oz.  (337.6  gm.),  which  leaves 
6  oz.  (184.6  gm.)  of  tissue  consumption  to  be  accounted  for. 

For  the  period  from  the  fourth  to  the  seventh  day  (inclusive)  I 
obtained  the  following  figures  : 

Total  amount  ingested,  50  oz.  (+  1539  gm.)  milk. 

Total  amount  excreted,  32f  oz.  (—  1013  gm.)  metabolic  products. 

Apparent  increase  in  body  weight,  17^  oz.  (+526  gm.). 

Actual  average  increase  in  weight,  7  oz.  (+  210  gm.). 

Again  the  increase  in  weight  is  less  than  would  be  expected 
from  the  calculation,  and  there  remain  10  oz.  (316  gm.)  of  tissue 
consumption  to  be  accounted  for. 

In  accordance  with  the  relatively  low  functional  activity, 
the  fetus  generates,  as  we  have  seen,  only  a  slight  amount 
of  heat  of  its  own.     As  soon  as  the  fetus  is  born  it  loses 

^  Reported  at  length  in  Arch.  f.  Gyn.,  1897. 


114    THE  PUERPERWM  AND  NEW-BORN  INFANT. 

a  large  proportion  of  this  heat  by  radiation,  but  this  loss 
is  made  good  by  the  establishment  of  many  new  functions 
which,  by  the  chemical  and  physical  processes  to  which 
they  give  rise,  generate  a  considerable  amount  of  warmth 
and  of  gases — the  chief  factors  in  this  heat  production 
being  the  pulmonary  and  cutaneous  respiration,  the  diges- 
tive processes,  and  chemical  cell-activity.  Hence  the  ex- 
cess of  ingested  milk,  as  seen  above,  is  used  for  this  heat 
production  and  not  for  the  purpose  of  building  up  the 
body  by  increasing  the  body  weight. 

The  disproportion  between  the  amount  of  nutriment 
supplied  in  the  milk  and  the  loss  in  weight,  or  the  unex- 
pectedly low  increase  in  weight  during  the  first  eight  or 
fourteen  days,  is  therefore  explained  by  this  consideration 
of  the  heat-producing  power  of  the  milk  and  of  cutaneous 
radiation ;  in  other  words,  by  the  heat  production. 

As  during  the  first  three  days  the  amount  of  milk  ingested  is 
not  sufficient  to  maiatain  the  necessary  degree  of  heat,  and  as  the 
rapidity  with  which  the  organs  in  general  accustom  themselves 
to  the  performance  of  their  new  functions  is  subject  to  individual 
variations,  the  body  during  this  time  consumes  its  reserve  sup- 
ply of  material  derived  from  the  mother.  Thus  I  found  that 
the  weight-curve  corresponded  with  the  temperature-curve  and 
with  the  curve  representing  the  total  amount  of  nitrogen  excreted 
in  the  urine.  This  phenomenon  undoubtedly  explains  the  so- 
called  physiological  icterus  which  is  so  often  seen  in  infants  in  the 
first  week,  and  which  is  probably  due  to  the  destruction  of  large 
numbers  of  red  corpuscles  (Hofmeier). 

The  body  temperature  is  extremely  variable  during  the 
first  few  days,  as  heat  production  and  heat  radiation  have 
not  yet  become  properly  regulated. 

The  temperature  of  the  skin  in  the  infant  is  77°  to  84.2°  F.  (25° 
to  29°  C.)  as  against  89.6°  to  93.2°  F.  (32°  to  34°  C.)  in  the  adult, 
because  the  radiation  in  the  former  is  so  much  more  active.  Thus, 
I  found  the  temperature  on  the  epigastrium  in  an  infant  which 
had  been  clothed  as  usual  on  the  average  97°  F.  (36.1°  C.)  during 
the  first  week  (in  boys  slightly  higher  than  in  girls),  while  in 
adults  it  is  only  95°  F.  (35°  C).  This  shows  how  important  it  is 
to  guard  the  infant  against  any  loss  of  heat  while  Schultze's 
method  or  other  similar  manipulations  are  performed  for  the  pur- 


PHYSIOLOGY  AND  FEEDING  OF  NEW-BORN  INFANT.  115 


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116    THE  PUERPERIUM  AND  NEW-BORN  INFANT, 

pose  of  establishing  respiration,  especially  as  the  rapidity  of  the 
cooling  process  increases  as  the  temperature  falls. 

The  loss  of  heat  experienced  from  the  time  of  birth 
until  the  first  bath  has  been  given  is  enough  to  produce 
a  fall  in  the  body  temperature  from  99.3°  F.  (37.4°C.)  to 
96.8°  F.  (36°  C.)  and  95°  F.  (35°  C).  The  fetus,  and 
similarly  the  new-born  infant,  immediately  after  birth  and 
until  the  heat  balance  has  been  established,  behaves  like 
a  poikilothermic  animal  or  like  those  mammals  which  are 
born  blind,  since  the  heat-producing  power  is  still  at  its 
minimum.  Hence  it  is  that  during  the  first  weeks  of  life 
ingestion  of  milk  and  the  first  crying  spell  are  immedi- 
ately followed  by  a  rise  in  the  body  temperature. 

The  temperature  varies  physiologically  from  97.8°  to 
98.6°  F.  (36.5°  to  37°  C). 

These,  then,  are  the  factors  which  influence  the  general 
physiological  changes  in  weight.  An  unusually  well- 
developed  infant  (over  8|  lb.  [4  kilos])  does  not  show 
these  changes  to  the  same  extent  as  does  a  normal  child 
of  average  weight  (6|  to  7^  lb.  [3100  to  3400  gm.]),  the 
loss  in  weight  on  the  fourteenth  day  being  IcvSS  while  the 
increments  are  greater ;  on  the  other  hand,  a  Aveakly  or 
premature  child  is  affected  very  much  more  unfavorably, 
and  is  also  much  more  apt  to  be  attacked  by  icterus. 

The  influence  of  the  mother  manifests  itself  in  the  fact  that 
the  children  of  primiparse,  under  the  age  of  twenty  and  weighing 
less  than  120  lb.  {bo  kilos),  show  the  least  tendency  to  increase 
their  weight  during  the  first  week,  and  the  same  is  true  of  the 
children  of  mothers  who  are  obliged  to  work  hard  during  preg- 
nancy and  who  are  not  able  to  nourish  themselves  properly  or  are 
attacked  by  disease.  This  relation  between  the  mother's  condi- 
tion and  the  size  of  the  fetus  enables  us,  if  necessary  on  account 
of  a  contracted  pelvis,  to  influence  the  weight  of  a  fetus  during 
pregnancy  by  dietetic  methods  (Prochownik's  diet). 

Conversely,  the  greatest  tendency  to  increase  of  weight  is  found 
in  children  born  of  women  weighing  over  120  lb.  (55  kilos)  and 
between  the  ages  of  twenty  and  twenty-nine,  especially  of  multi- 
parae;  the  latter  also  produce  on  the  average  more  boys  than  girls. 
Vigor  in  the  father  usually  compensates  for  the  maternal  weak- 
ness in  the  matter  of  the'  infant's  weight ;  even  the  temporary 
condition  of  the  father  at  the  time  of  impregnation  has  some  in- 


PHYSIOLOGY  AND  FEEDING  OF  NEW-BORN  INFANT.  117 

fluence  in  this  respect.  In  marriages  between  different  races  the 
peculiar  qualities  of  race,  nationality,  or  tribe  manifest  themselves 
in  this  matter  of  the  child's  weight;  thus,  marriages  between 
Ano-lo-Saxon  men  and  Japanese  women  usually  result  untavorably 
for  Uie  mother,  because  the  broad  skull  of  the  infant  is  unable  to 
pass  the  narrow  and  circular  pelvis  ;  on  the  other  hand,  marriages 
between  Anglo-Saxons  and  Latins  usually  give  favorable  results. 

These  relations  affect  the  absolute  weight  of  the  child 
at  birth  as  well  as  the  subsequent  changes  in  weight ;  the 
greater  the  body  weight  of  a  vigorous,  healthy  mother, 
the  greater  is  the  average  increase  in  the  weight  of  the 
child  ;  although  there  are  certain  typical  differences  in 
the  average  weight,  depending  on  whether  the  child  is 
the  first-born  or  not,  the  first-born  being  usually  the 
lightest. 

The  children  of  tuberculous  or  scrofulous  mothers  show  an 
average  deficit  of  6.2  per  cent,  of  their  initial  weight  as  late  as 
the  fourteenth  day,  as  against  0.14  per  cent,  in  children  born  of 
healthy  mothers ;  while  the  latter  put  on  weight  at  the  average 
rateof- Uoz.  (35  gm.)  per  day  during  the  first  month,  and  1  oz. 
28  gm.)  per  dav  during  the  second  month,  the  children  ot_  tuber- 
culous mothers  on  the  average  show  no  increase  at  all  during  the 
first  month  and  only  62  gr.  (4  gm.)  per  day  during  the  second 

"^ The*  average  weight  of  children  of  healthy  and  of  diseased 
fathers  is  represented  by  the  following  proportion:  124:92  oz. 

(3500 :  2600  gm.).  ,  -ui.  ^i^A,, 

Diabetes  in  the  mother  exerts  an  even  more  unfavorable  ntlu- 
ence  than  do  the  diseases  just  mentioned;  5  per  cent,  of  children 
born  of  diabetic  mothers  die  before  term. 

The  same  is  true  of  syphilitic  transmission.  Children  born  of 
syphilitic  mothers  who  are  healthy  at  birth  and  remain  healthy 
show  a  much  smaller  increase  or  a  greater  decrease  in  weight  on 
the  average  than  the  children  of  healthy  mothers  This  may  be 
accounted  for  in  part,  but  only  in  part,  by  the  artificia   feeding. 

Heavy  children-over  8f  lb.  (4  kilos)-are  more  ?ften.borb 
even  from  primiparse,  among  the  better  classes  than  m  lyingyin 
hospitals.  This  is  due  to  over-feeding  during  pregnancy  and  in- 
sufficient bodilv  exercise.  •  4.    +i.^  ^^ 

It  should  also  be  mentioned  that  nature  often  assists  the  ott- 
sprino-  of  debilitated  mothers  at  the  latter's  expense.  Ihus,  the 
child?en  maybe  born  perfectly  healthy,  even  ^vhen  the  mother 
during  pregnancy  was  insufficiently  nourished  ^^^^^^^y' ^^^^Xn 
the  birth  of  her  infant  the  mother  suddenly  collapses  and  often 


118    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

does  not  recover  for  months,  even  with  the  most  careful  nursing, 
or  else  does  not  recover  at  all  and  falls  a  victim  to  tuberculosis. 

A  knowledge  of  these  facts  is  important  in  determin- 
ing the  prognosis  of  a  birth  in  cases  of  contrac^ted  pelvis 
and  the  probable  effect  of  methods  of  feeding  on  the 
infant. 

In  general,  artificial  feeding  in  healthy  children  is 
never  or  hardly  ever  followed  by  the  same  increase  in 
weight  and  general  improvement  as  when  the  child  is  fed 
from  the  breast. 

If  we  compare  the  body  weights  of  healthy  children  brought 
up  by  Soxhlet's  method  with  that  of  breast-fed  children  we  find 
that  the  former  regain  their  initial  weight  on  the  fourteenth  day 
very  much  more  rarely  than  do  the  latter;  we  also  find  a  greater 
average  decrease  in  weight :  7.3  per  cent,  as  against  5.5  per  cent. 
— yielding  an  average  of  3.7  per  cent,  instead  of  0.14  per  cent. 
(In  Soxhlet's  method — sterilization — the  milk,  after  being  diluted 
with  water  and  enriched  with  sugar  of  milk  to  make  it  more  like 
human  milk,  is  boiled  from  ten  to  twenty  minutes  for  the  purpose 
of  killing  fermentation  fungi  and  tubercle  and  other  bacilli).  In 
the  urine  the  loss  of  phosphorized  albuminates  in  the  form  of 
pseudonuclein  from  cow  casein  has  been  demonstrated.  Mother's 
milk  is  very  completely  utilized  by  the  new-born  during  the 
second  week,  as  shown  by  the  following  table  (Mischel,  Uffelmann, 
Wegscheider) : 

Nutritive  substances  in  general 96.11  per  cent. 

Fat 96.35       '' 

Nitrogenous  substances    . 93.60 

1.486  gm.  mineral  salts 78.26       " 

.243  gm.  calcium 59.42 

.263  gm.  phosphoric  acid 91.63       " 

Breast-fed  children  show  a  daily  increase  of  about  1  oz. 
(30  gm.)  during  the  first  and  second  months,  while  those 
fed  artificially  show  at  first  only  6  drams  (23  gm.)  and 
later  5  drams  (1 9  gm.).  We  have  already  shown  how  easily 
the  digestive  function  may  be  disturbed  in  artificial  feed- 
ing, either  by  the  inability  of  the  child  to  digest  the  casein 
or  by  the  occurrence  of  an  infectious  gastro-enteritis  ; 
if,  however,  the  infant  remains  well^  the  loss  of  weight  is 
made  good  during  the  second  half  of  the  first  year,  when 
every  child  is  capable  of  assimilating  a  mixed  diet.     In 


PHYSIOLOGY  AND  FEEDING  OF  NEW-BORN  INFANT.  119 

any  case  the  injurious  effects  of  artificial  feeding,  which 
rarely  fail  to  put  in  their  appearance  during  the  first  six 
months  of  life,  tend  to  diminish  the  resisting  power  of 
the  infantile  organism.  As  the  infant  in  this  early  stage 
is  quite  capable  of  digesting  prepared  starch  (that  is,  to 
convert  it  into  soluble  sugar),  as  has  been  shown  by  ex- 
perience as  well  as  by  the  latest  investigations,  we  are 
quite  justified  in  adding  prepared  farinaceous  foods  to  the 
milk  as  early  as  possible,  whenever  the  milk  alone  proves 
insufficient.  The  oldest  preparation  of  this  kind  is 
Nestle's  infant  food,  consisting  of  sterilized  milk  thick- 
ened with  a  kind  of  zwieback  meal  and  a  little  cane- 
sugar.  I  have  also  obtained  good  results  with  Fiirther^s 
"  Kinderzwieback,^^  with  similar  preparations  manu- 
factured by  Kufeke,  by  Wagner  of  Stuttgart  (whose  food, 
however,  gives  the  urine  an  irritating  quality  that  some- 
times causes  intertrigo),  and,  finally,  by  Theinhardt.  Oat- 
meal mixed  with  boiled  zwieback  meal  often  answers  the 
same  purpose.  Recently  malt-soup  has  been  given  with 
some  success  to  marasmic  infants,  and  as  early  as  the  first 
week  to  infants  suffering  from  gastro-intestinal  disease. 
(To  24  oz. — 750  gm.  malt-soup  add  5  oz. — 150  gm.  of 
water,  so  that  it  contains  a  smaller  proportion  of  milk 
and  flour  and  a  greater  proportion  of  malt  extract  than 
Liebig's  extract.) 

As  we  have  seen,  the  new-born  infant  requires  a  large 
amount  of  heat-producing  substances — 3  J  oz.  (100  gm.) 
of  albumin  (the  casein  in  cows'  milk  is  very  much  in  ex- 
cess of  that  contained  in  human  milk  and  is  practically 
indigestible  for  the  child)  yields  only  as  much  heat  as 
l-J  oz.  (52  gm.)  of  fat,  hence  the  infant's  digestive  tract 
is  at  first  better  adapted  to  the  assimilation  of  milk  rich 
in  fat  and  poor  in  albumin.  By  the  process  of  centrif- 
ugation  a  part  of  the  casein  can  be  mechanically  re- 
moved from  cows'  milk ;  hence  the  question  of  artificial 
feeding  is  theoretically,  at  least,  best  solved  in  this  way. 
Any  dairy  can  manufacture  this  Gartner's  ^'  Fettmilch  " 
by  means  of  the  centrifugal  machine,  and  the  use  of  this 


120    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

modified  milk  undoubtedly  yields  very  good  results,  but 
it  is  far  from  realizing  the  ideal  of  an  artificial  food.  I 
have  seen  many  children  who  were  fed  on  this  prepara- 
tion fail  to  gain  weight  as  they  should,  when  the  addition 
of  the  above-mentioned  substances  produced  satisfactory 
results. 

The  best  method  of  preparing  artificial  milk  is  that 
of  Heubner-Soxhlet,  and  it  can  be  prepared  from  good 
fresh  cows'  milk  as  it  is  delivered  at  our  doors  every  day. 
The  milk  is  boiled  for  from  ten  to  twenty  minutes  (if  the 
milk  is  boiled  longer  than  this  it  becomes  even  more  in- 
digestible than  it  was  at  first),  and  after  having  been 
diluted  according  to  the  age  of  the  child  in  the  propor- 
tion of  1  :  3,  1  :  1,  and,  finally,  3  :  1,  is  enriched  by 
the  addition  of  5  per  cent,  of  milk-sugar  (sterilized  and 
chemicallv  pure  preparation  of  Loflund),  temperature 
95°  F.  (35°  C). 

The  milk  is  to  be  well  shaken  before  it  is  poured  into 
the  bottles  supplied  with  Soxhlet's  apparatus,  and  contain- 
ing from  2  to  6^  fl.  oz.  (50  to  200  c.c),  so  that  each  bottle 
may  contain  the  same  percentage  of  fat. 

After  the  mixture  has  been  })repared  according  to  the 
table,  the  entire  battery  of  bottles  is  boiled  at  once  from 
ten  to  twenty-five  minutes,  and  the  bottles  are  then  closed 
with  the  automatic  air-tight  stoppers.  The  latter  are  not 
essential  ;  it  is  far  more  important  to  cool  the  milk  at 
once,  although  there  is  some  danger  of  breaking  the  bot- 
tles. To  avoid  expense  the  mixture  may  be  boiled  in  an 
ordinary  pot,  the  directions  being  carefully  followed. 

It  is  one  of  the  most  important  duties  of  the  state  to  keep  up  a 
high  standard  of  cattle  by  constant  addition  from  healthy  dis- 
tricts and  the  importation  of  good  Swiss  and  Dutch  or  other 
breeds  from  low  countries,  to  insist  on  proper  feeding  and  care,  to 
discourage  the  custom  of  keeping  cows  in  stables  or  pasturing 
them  on  lands  overgrown  with  weeds  unfit  for  the  production  of 
milk,  and,  finally,  to  exclude  all  but  the  best  quality  of  milk  from 
the  general  market,  as  was  done  with  great  success  by  a  private 
individual  in  Berlin.  Like  many  other  hygienic  regulations  this 
matter  should  be  subject  to  the  immediate  supervision  of  public 


PHYSIOLOGY  AND  FEEDING  OF  NEW-BORN  INFANT.  121 

boards  of  health.  The  inability  to  nurse  children  is  increasing  to 
an  alarming  extent  in  many  regions ;  even  the  rural  population  is 
deteriorating  in  this  respect,  and  a  dearth  of  wetnurscs  is  begin- 
ning to  be  felt.  Physicians  nowadays  often  meet  with  country 
women  suffering  from  so-called  nervous  dyspepsia,  chlorosis,  and 
neurasthenia,  symptoms  which  are  without  exception  to  be  attrib- 
uted to  diminished  powers  of  resistance. 

The  relative  deficiency  in  carbohydrates  in  the  milk 
mixture  M'hich  I  have  described  is  corrected  by  the  addi- 
tion of  5  to  6  per  cent,  of  milk-sugar.  In  spite  of  this, 
however,  most  children  do  not  thrive  as  they  should,  and 
if  the  number  of  feedings  is  increased^  or  more  concen- 
trated milk  is  used,  the  digestion  usually  suffers.  In  such 
cases  the  preparations  of  milk  and  zwieback  meal  should 
be  resorted  to,  or,  if  possible,  a  good  wetnurse  should  be 
procured.  This  is  often  difficult,  troublesome,  and  expen- 
sive, as  it  is  not  always  possible  to  be  sure  of  the  health 
and  moral  fitness  of  a  wetnurse,  but  if  these  conditions 
can  be  obtained,  it  is  the  most  rational  method  of  feeding. 
From  an  ethical  point  of  view  the  question  is  frequently 
hard  to  decide,  as  it  not  rarely  involves  the  entire 
abandonment  of  the  wetnurse's  child.  A  physician  is 
never  justified  in  procuring  a  healthy  nurse  for  a  syph- 
ilitic child,  or  even  in  giving  his  consent  to  such  a  pro- 
cedure. 

A  good  wetnurse  should  possess  the  following  qualifi- 
cations :  Her  general  condition  must  be  perfect,  above 
all,  tuberculosis  and  syphilis  must  be  excluded  ;  the 
breasts  must  be  well  developed,  both  as  regards  the  gland- 
ular structure  and  the  nipples.  The  size  of  the  mamma 
is  frequently  due  to  excessive  adipose  tissue,  as  we  often 
have  occasion  to  see  in  the  beer  districts  in  Bavaria.  The 
physician  will  do  well  to  reserve  his  judgment  in  the  case 
of  an  unknown  nurse  until  the  following  day,  as  employ- 
ment bureaus  very  often  prepare  the  nurses  by  giving 
them  large  amounts  of  beer  and  taking  away  the  child  ; 
the  fitness  of  a  nurse  is  always  best  determined  by  the 
examination  of  her  own  child.  The  milk  should  contain 
at  least  so  much  fat  that  after  twentv-four   hours  one- 


122    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

tenth  of  the  volume  rises  to  the  surface  in  the  form  of 
cream.  The  diet  and  general  care  of  the  nurse  should  he 
such  as  she  has  been  used  to  before,  as  far  as  the  altered 
circumstances  will  permit.  Nurses  are  very  apt  to  be- 
come lazv  and  careless  about  their  persons ;  they  should 
be  carefully  looked  after  and  made  to  do  some  light  form 
of  house-work.  A  nurse's  disposition  should  be  gentle 
and  good-natured,  and  she  must  not  be  the  subject  of  any 
nervous  trouble.  Some  of  these  qualities  ought  also  to 
exist  in  mothers  if  they  are  to  be  allowed  to  nurse  their 
own  children. 

If  for  any  reason  a  nurse  is  not  wanted  or  cannot  be 
obtained,  the  addition  of  natural  milk  fat  to  the  milk, 
diluted  as  described  above,  furnishes  a  satisfactory  method 
of  increasing  the  nutritive  value  of  the  milk-and-water 
mixture  without  injuring  its  digestibility.  Among  prepa- 
rations of  this  kind  we  have  Biedert's  ^' Rahmgemenge" 
(cream  mixture)  and  Soldner's  '^  Eahmkonserve ''  (con- 
densed or  preserved  cream — Loflund). 

The  use  of  these  preparations  depends  on  a  chemical  compari- 
son between  human  milk  and  cows'  milk,  it  being  found  that  the 
chemical  constitution,  so  far  as  we  know,  of  cows'  milk  approaches 
that  of  human  milk  if  Ij  gr.  (0.1  gm.)  of  nitrogen  from  albumin, 
If  drachms  (7  gm.  cream  fat),  6  drachms  (25  gm.)  of  sugar  of  milk, 
and  8  fl.  oz.  (250  c.c.)  of  water  are  added  to  8  fl.  oz.  (250  c.c.)  of 
cows'  milk — which  contains  18i  drachms  (1.2  gm.)  nitrogen  from 
albumin,  2\  drachms  (8.7  gm.)  fat,  3  drachms  (11  gm.)  carbohy- 
drates, 2(3  gr.  (1.7  gm.)  ash.  In  practice  such  a  mixture  is  obtained 
for  a  child  fourteen  days  old,  for  instance,  by  mixing  one-fourth 
of  a  quart  (liter)  of  cows'  milk  w^ith  7 J  fl.  oz.  (220  c.c.)  of  water, 
7  drachms  (28  gm.)  of  *' Rahmkonserve,"  3J  drachms  (14  gm.) 
milk-sugar,  making  in  all  18  fl.  oz.  (530  c.c). 

The  Subsequent  Care  of  the  Infant. — Im- 
mediately after  birth  the  eyes  are  to  be  wiped  clean.  If 
there  is  any  suspicion  of  gonorrhea,  one  to  two  drops  of 
a  2  per  cent,  solution  of  argentic  nitrate  are  to  be  in- 
stilled into  the  eyes  and  moist  compresses  put  on.  The 
navel  readily  becomes  infected  and  the  following  direc- 
tions are  therefore  to  be  observed  : 


HYGIENE  AND  3IANAGEMENT  OF  PREGNANCY.   123 

1st.  The  nurse  is  to  attend  to  the  child  first,  and  see 
that  her  liands  and  especially  her  finger-nails  are  clean. 

2d.  The  stump  should  dry  as  quickly  as  possible  ;  this 
process  of  mummification  is  assisted  by  dusting  the  stump 
with  any  desiccating  and  disinfecting  powder  (the  author 
prefers  nosophen  and  starch,  or  bismuth  and  starch,  or 
powdered  salicylic  acid)  and  wrapping  it  loosely  in  salicyl- 
ated  cotton.     Ahlfeld  suggests  alcohol  compresses. 

3d.  The  child  is  to  be  sponged  twice  daily,  and  not  to 
be  given  a  full  bath  until  the  cord  has  come  away  and 
the  \vound  is  closed  ;  after  that  it  may  be  bathed  in  water 
at  the  temperature  of  95°  F.  (35°  C).  Many  infants  bear 
warm  baths  very  badly. 

On  the  first  day  the  proper  evacuation  of  meconium 
and  urine  must  be  attended  to.  The  child  is  to  be  fed 
every  two  or  three  hours,  the  first  feeding  to  take  place 
twelve  hours  after  birth,  either  at  the  breast  or  with  the 
bottle,  the  diaper  being  changed  first.  The  mouth  is  to 
be  wiped  with  a  soft  moist  cloth  before  the  child  is  fed. 
In  the  intervals  between  feeding  the  infant  must  not  be 
disturbed.  It  ought  to  be  part  of  the  infant's  education, 
as  it  is  a  sign  of  its  good  health,  that  it  slee])  uninter- 
ruptedly from  10  or  11  o'clock  at  night  till  5  o'clock 
in  the  morning,  and  this  may  be  achieved  by  the  end 
of  the  first  month.  The  habit  of  carrying  the  baby 
about  and  singing  it  to  sleep  is  a  senseless  maternal 
weakness  and  one  that  most  nurses  are  unfornately  ad- 
dicted to.  The  mother  or  nurse  should  never  be  allowed 
to  take  the  child  into  bed  with  her,  either  because  of  lazi- 
ness or  for  the  purpose  of  warming  it,  as  it  is  a  most 
dangerous  practice. 

^  lo.  HYGIENE  AND  MANAGEMENT  OF  PREGNANCY. 

The  management  of  a  pregnant  woman  has  for  its  main 
objects  the  alleviation  or  prevention  of  certain  physiolog- 
ical disturbances  which  are  most  apt  to  occur  and  are  most 
marked  in  neurotic  individuals,   the  preparation   of  the 


124    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

woman  for  the  birth  and  subsequent  feeding  of  her  child, 
and,  finally,  the  prevention  of  injuries  which  are  liable  to 
occur  as  pregnancy  advances,  or  at  the  time  of  parturition, 
or  during  the  puerperium. 

Above  all,  the  physician  should  combat  the  idea  that 
pregnancy  is  an  abnormal  condition  and  that  the  pregnant 
woman  should  be  as  careful  of  herself  as  if  she  were  ill. 
On  the  other  hand,  she  should  avoid  anything  like 
dissipation  and  live  a  regular  life.  By  this  means  we 
may  hope  to  avoid  any  serious  disturbances  during  preg- 
nancy, such  as  vomiting,  constipation,  or  attacks  of 
vertigo.  The  diet  should  consist  of  easily  digestible  and 
non-irritating  foods  that  have  no  tendency  to  produce 
fermentation  and  flatulency ;  alcoholic  beverages  should 
be  avoided.  The  bowels  must  be  regulated  by  appropriate 
vegetable  diet  and,  if  necessary,  by  the  administration  of 
enemata  or  even  mild  purgatives.  The  clothing  should 
be  loose  and  comfortable.  Corsets  should  be  avoided  on 
account  of  the  downward  pressure  which  they  exert ;  they 
may  be  appropriately  replaced  by  elastic  corset-waists  to 
which  the  underclothing  can  be  buttoned.  All  pressure 
on  the  breasts  must  be  avoided.  If  the  abdominal  walls 
are  weak,  binders  should  be  worn  during  the  second  half 
of  pregnancy  to  prevent  the  development  of  '^  pendulous 
abdomen. ^^  Mental  depression  is  best  avoided  by  appro- 
priate feminine  duties  and  pursuits  such  as  keep  body 
and  mind  occupied,  and  furthermore  by  the  assurance, 
based  on  accurate  examination,  that  everything  is  in  good 
order.  The  woman  should  be  provided  with  sensible 
companionship  and  light  and  agreeable  entertainment,  all 
gossiping  and  recounting  of  horrible  deliveries  being 
strictly  forbidden  ;  and,  finally,  she  should  be  assured  that 
all  the  necessary  preparations  for  a  proper  delivery  have 
been  carefully  attended  to.  If  it  seems  advisable,  admit- 
tance to  a  maternity  hospital  will  contribute  greatly  to 
preserve  the  patient's  peace  of  mind. 

In  the  care  of  the  skin  of  the  breasts  and  abdomen  the 
most  important  point  is  a  daily  sponging  with  cool   or 


SY3IPT0MAT0L0GY  AND  MANAGEMENT.        125 

tepid  water.  Hot  baths  I  do  not  consider  necessary  except 
for  the  purpose  of  producing  diaphoresis  in  cases  of  renal 
disease ;  for  purposes  of  cleanliness  a  full  bath  every 
week  or  every  other  week  in  addition  to  the  daily  spong- 
ing is  quite  sufficient.  The  last  bath  should  be  taken 
shortly  before  the  onset  of  labor-pains.  I  do  not  recom- 
mend the  use  of  astringent  lotions  on  the  nipples,  but 
gentle  manipulation  is  often  necessary  to  draw  out  one 
that  is  imperfectly  developed.  Above  all,  cleanliness  is 
to  be  enjoined. 

In  the  examination  of  a  pregnant  woman,  which  in- 
cludes a  careful  examination  of  the  size  and  shape  of  the 
pelvis,  the  attention  should  be  directed,  above  all,  to  the 
kidneys  and  to  the  heart,  and,  if  either  of  these  organs  is 
found  insufficient,  energetic  treatment  is  to  be  inaugurated 
at  once.  In  chlorotic  women  it  is  not  advisable  to  resort 
to  forced  feeding  toward  the  end  of  pregnancy,  as  such  a 
course  rarely  benefits  the  mother,  w^hile  it  leads  to  exces- 
sive growth  of  the  fetus  which  may  seriously  embarrass 
parturition. 

g  II.  SYMPTOMATOLOGY    AND  MANAGEMENT  OF   THE 

PUERPERIUM. 

The  puerperium  includes  the  involution  of  the  genera- 
tive organs,  the  establishment  of  lactation,  and  the  result- 
ing changes  in  the  circulation  and  in  metabolivsm.  In 
civilized  women  rest  in  bed  for  from  one  to  two  weeks 
(in  the  dorsal  position  during  the  first  twenty-four 
to  twenty-eight  hours)  is  necessary  for  the  accomplish- 
ment of  these  changes.  It  cannot  be  denied,  however, 
that  strong,  healthy  women  who  are  nursing  their  children 
are  quite  able  to  return  to  their  ordinary  occupations  on 
the  third  or  fourth  day,  and  that  the  involution  of  the 
organs  progresses  even  better  under  such  circumstances, 
providing,  always,  that  no  infection  has  taken  place. 
Kiistner  made  some  experiments  in  this  line  in  his  clinic 
with  very  good  results.  Elasticity  of  the  abdominal  mus- 
cles, ligaments,  and  blood-vessels  is  a  necessary  prerequisite. 


126    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

First  Day,  Second  Half. — Peptone  and  sugar  are 
present  in  the  urine,  sometimes  there  is  retention.  Warm 
irrigation  and  compresses  are  useful ;  the  catheter  should 
be  used.  Afterpains  occur  in  multiparse.  Diaphoretics 
should  be  given.  The  uterus  is  anteflexed  and  flattened 
from  before  backward,  its  length  is  appreciably  dimin- 
ished ;  the  fundus  is  almost  at  the  level  of  the  umbilicus. 
Pulse  from  40  to  70 ;  bloody  lochial  discharges. 

Diet  during  the  First  Three  Days. — Two  cups 
of  milk,  one  soft-boiled  egg,  a  few  zwieback,  given  in 
five  meals.     At  night  w^ater  or  milk. 

Second  Day. — If  the  bladder  is  empty  the  fundus  of  the 
uterus  stands  about  a  hand's  breadth  above  the  symphysis. 
The  dorsal  position  should  be  maintained  until  the  third 
or  the  fifth  day ;  after  that  the  woman  should  lie  on  her 
side,  especially  if  there  is  any  tendency  to  retroversion 
or  retroflexion.  The  bladder  must  be  emptied  at  least 
twice  a  day.  After  each  evacuation  ih^  vulva  should  be 
irrigated  either  with  boiled  water  or  w^ith  0.5  per  cent, 
sublimate  or  1  to  2  per  cent,  carbolic-acid  solution  or 
0.5  per  cent,  lysol  solution,  and  wiped  dry  with  cotton. 
If  there  are  any  excoriations  or  fissures  about  the  vulva, 
or  sutured  perineal  tears,  they  must  be  dusted  with  noso- 
phen  powder  (dermatol,  iodoform,  and  so  on)  or  covered 
with  airol  or  zinc  paste,  after  which  a  vulvar  pad  is  placed 
on  the  labia.  Diaphoresis  should  be  encouraged.  In 
multiparse  lactation  begins. 

In  the  infant's  umbilicus  the  line  of  demarcation  sepa- 
rating the  mummifying  umbilical  cord  appears,  and  is  at- 
tended with  slight  exudation  ;  the  cord  is  to  be  dusted 
with  salicylic  powder,  or  nosophen,  or  bismuth  and  starch 
powder  and  loosely  wrapped  in  cotton ;  the  child  is  never 
to  be  completely  immersed  in  the  bath  until  the  navel  is 
entirely  healed,  so  as  to  keep  the  cord  dry.  The  child  is 
fed  for  the  first  time  twelve  hours  after  birth,  and  its 
navel  and  eyes  should  always  be  attended  to  before  the 
mother. 

Third  Day. — The  breasts  have  reached  their  highest 


SYMPTOMATOLOGY  AND  MANAGEMENT.        127 

degree  of  distention ;  the  fundus  is  a  hand's  breadth 
above  the  symphysis.  Beginning  of  serous  lochia,  which 
are  of  a  pale  meat  color  and  have  a  peculiar  stale  odor. 
If  the  lochia  remain  bloody  for  several  days,  and  after- 
pains  continue,  it  is  a  sign  of  endometritis.  Under  such 
conditions  the  discharges  readily  become  fetid.  Primiparse 
suffer  less  from  afterpains  and  the  bloody  lochia  last 
longer,  because  involution  progresses  more  slowly.  The 
phvsiological  variation  in  temperature  during  these  days 
is 'between  98.6°  and  100.4°  F.  (37°  and  38°  C.) ;  a 
temperature  above  100.4°F.  (38°  C.)  is  to  be  regarded  as 
febrile.  Evacuation  of  the  bowels  must  be  carefully  at- 
tended to. 

Fourth  Day. — The  fundus  uteri,  in  other  words,  the 
highest  point  of  the  posterior  wall,  is  midway  between 
the  symphysis  and  the  umbilicus.  The  colostrum  changes 
to  thin,  watery  milk.  Most  abundant  milk  secretion ; 
diminution  of  the  lochia.  Greatest  percentage  of  nitro- 
gen in  the  urine. 

The  umbilical  cord  in  the  child  separates,  although  some- 
times not  until  the  sixth  day.  Up  to  this  time  the  alvine 
discharges  have  consisted  of  meconium  (the  saline  colostrum 
acts  as  a  purge) ;  from  now  on  the  stools  are  yellow,  like 
saffron  or  yolk  of  e^^^  with  very  minute  sediment ;  if  the 
child  is  fed  on  cow's  milk  the  stools  contain  coarse,  firm 
particles.  Up  to  this  time  the  bodv  weight  diminishes. 
Temperature— 98.4°  to  100°  F.  (36.8°  to  37.7°  C.)— 
highest  after  nursing,  that  is,  usually  at  noon.  Physio- 
logical icterus  most  intense.  From  now  on  dailv  full 
bath  at  89.2°  F.  (31.7°  C).  Some  children  do  not  bear 
this  very  well,  and  must  be  washed  daily  in  tepid  water 
and  given  a  full  bath  only  once  a  week. 

Diet  from  the  Fourth  to  the  Sixth  Day. — Three 
cups  of  milk  (with  a  little  coffee  or  tea),  one  plate  of 
bouillon,  two  saucers  of  oatmeal  or  other  cereal,  one  egg, 
a  quarter  of  a  pound  of  chopped  white  meat.  Three 
times  a  day  a  zwieback  or  a  roll,  once  a  day  some  diges- 
tible preserves  (apple).     The  above  to  be  given  in  five 


128    THE  PUERPEBIUM  AND  NEW-BORN  INFANT. 

meals.  At  night  sugar-water  with  lemon,  or  milk,  pos- 
sibly a  glass  of  good  Burgundy,  or  broth. 

Eighth  Day. — Lochia  alba  begin.  The  cervix  usu- 
ally admits  one  finger  and  the  placental  site  can  be  felt  as 
a  roughened  area;  the  uterus  is  anteflexed  ;  the  fundus 
three  fingers'  breadth  above  the  symphysis.  Colostrum 
corpuscles  have  disappeared  from  the  milk. 

The  child  in  one-half  of  the  cases  regains  its  original 
weight.     The  temperature  becomes  more  stable. 

Ninth  Day. — The  fundus  uteri  or,  if  the  anteflexion 
is  marked,  the  highest  point  of  the  posterior  wall  is  be- 
hind the  symphysis.  The  external  os  begins  to  close;  the 
vaginal  portion  of  the  cervix  begins  to  project  freely  into 
the  vagina.  After  this  day  the  woman  may  get  up  if 
she  wishes  to.  Great  care  is  necessary  to  guard  against 
attacks  of  syncope  and  embolism. 

Diet  for  the  Seventh  to  the  Twelfth  Day.— Two 
cups  of  milk  (with  a  little  coffee  or  tea)  or  cocoa.  Three 
times  a  day  bread  of  some  sort ;  one  e^gg.  Twice  a  day 
rice,  farina,  oatmeal,  whole  oats,  or,  if  desired,  a  little 
scraped  raw  meat,  ham,  or  beef-steak  ;  a  quarter  of  a  pound 
of  roast  white  meat  once  a  day ;  some  digestible  vegetable 
(rice  or  farina) ;  preserves ;  one  plate  of  bouillon  once  a 
day  ;  broth  ;  possibly  two  glasses  of  Burgundy  or  lemon- 
ade.     Give  the  above  in  five  meals.     At  night,  milk. 

Twelfth  Day. — It  is  advisable  for  the  woman  to  get 
up.  She  should  not  remain  in  bed  any  longer  except  for 
a  special  reason  ;  in  weak  individuals  a  longer  rest  in  bed 
leads  to  general  relaxation,  especially  of  the  pelvic  organs. 
After  the  third  week  the  uterus  sinks  below  the  pelvic 
brim. 

The  child  now  gains  weight  at  the  average  rate  of  f  to 
1^  oz.  (20  to  35  gm.)  per  day.  It  should  be  put  to  the 
breast  every  three  (or  two  and  one-half)  hours  or  given 
2f  to  31  fl.  oz.  (85  to  110  c.c.)  of  the  milk-mixture,  3  :  1 
milk.  It  must  now  be  accustomed  to  sleep  through  the 
night  from  10  P.  M.  to  5  A.  M.  without  any  food.  During 
the  day  it  should  be  allowed  to  sleep  as  much  as  it  pleases. 


SYMPTOMATOLOGY  AND   MANAGEMENT.        129 

Fourth  to  Sixth  Week. — The  involution  of  the 
uterus  is  completed.  The  lochial  discharges  cease. 
Anatomically  the  placental  site  is  still  visible  as  a  marked 
prominence. 

At  the  end  of  the  tirst  month  the  child  weighs  on  the 
average  between  7|  and  8J  lb.  (3.5  and  4  kilos),  after  six 
weeks,  from  8|  to  9J  lb.  (4  to  4.5  kilos).  Milk-mixture, 
2  :  1  milk,  24  to  27  fl.  oz.  (700  to  800  c.c). 

Sixth  to  Eighth  Week. — Return  of  menstruation 
in  those  women  who  are  not  nursing  their  children.  In 
debilitated  women  or  in  those  who  are  suffering  from 
metritis  this  period  is  apt  to  be  verv  profuse. 

The  child  weighs  from  9^  to  10^  lb.  (4}  to  4f  kilos). 
Milk-mixture,  1  :  1  milk,  27  to  31  fl.  oz.  (800  to  900  c.c). 
Artificially  fed  children  weigh  a  little  less,  but  they 
usually  make  up  this  difference  at  the  time  when  all 
children  begin  to  take  a  mixed  diet. 

During  the  third  month  the  mixture  should  be  1  :  2 
milk,  31  to  34  fl.  oz.  (900  to  1000  c.c).  After  that,  1  :  3, 
and  the  proportion  of  milk  gradually  increased  to  1  quart 
(1000  c.c).  During  the  fifth  or  sixth  month  in  many 
cases  cows'  milk  can  be  given  (1  quart  =  1000  c.c  roughly), 
after  the  eighth  month,  2^  pints  (1200  c.c)  of  milk. 

AVeaning,  or,  in  the  case  of  artificially  fed  children, 
the  change  to  mixed  diet,  should  be  effected  from  the 
ninth  to  the  twelfth  month,  depending  chiefly  on  the  time 
of  the  first  dentition,  which  varies  with  the  constitution. 
The  diet  should  consist  of  2\  pints  (1200  c.c.)  of  milk, 
and  in  addition,  eo^^^^  bouillon  (the  child  may  be  al- 
lowed to  suck  pieces  of  meat),  puree  of  meat,  various 
kinds  of  soft  food,  spinach,  apple-sauce,  and  orange-juice. 


I 


Table  of  Dextitiox. 
6th  to    9tli  )  . ,     -1,    ^.  -     1  1  •    ^-  ^ .,   I  by   the  end   of 

5th  to    7th  f  ^^^"^^'  t^^  *^*^  ^^'^^^■^l  ^^^^^  mcisors,  |     ^^^^^  g^^^  ^^^^. 
8th  to  10th  month,  the  two  central  upper  incisors,    \     all     the      in- 

12th  to  15th  month,  the  two  lateral  upper  incisors,     |      cisors    h  ave 

11th  to  r2th  month,  the  two  lateral  lower  incisors,    J      erupted. 

14th  to  16tli  month,  four  bicuspids. 

18th  to  20th  month,  four  canines. 

22d   to  26th  month,  four  molars. 


130    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

The  Child  Weighs: 

End  of  3d  month,  10^  to  12  lb.  (4S  to  5i  kilos). 

"  4th  "  12  to  14i  lb.  (5i  to  Qh  " 

"  5th  "  13i  to  141  lb.  (6  to  6|  " 

"  6th  "  14i  to  15.V  lb.  (6^  to  7  " 

"  7th  "  15i  to  173  lb.  (7  to  8  " 

"  8th  "  16  to  18i  lb.  (7^  to  8i  " 

"  9th  "  16J  to  211  lb.  (7§  to  85  " 

"  10th  "  171  to  19J  lb.  (8  to  9  " 

"  12th  "  194  to  20^  lb.  (9  to  9^^  " 

Treatment  of  the  Puerpera. — We  have  seen  that 
the  physiological  object  of  the  poerperium  is  in  the  first 
place  the  involution  of  the  organs  of  gestation  and  of 
their  supporting  structures,  among  which  we  include  the 
pelvic  peritoneum  and  the  abdominal  walls,  and  further, 
the  restoration  of  the  organs  of  nutrition,  respiration,  cir- 
culation, and  excretion,  which  all  share  more  or  less  in 
the  metabolic  changes  incident  to  pregnancy.  The  in- 
volution of  the  former  is  the  slowest,  and  the  length  of 
time  during  which  the  woman  remains  in  bed  is  there- 
fore determined  by  its  progress  :  as  long  as  the  lochia! 
discharges  contain  blood  or  the  uterus  can  be  felt  above 
the  symphysis,  the  puerpera  must  remain  in  bed,  otherwise 
there  is  danger  of  a  chronic,  persistent  congestion  predispos- 
ing to  other  inflammatory  changes  (metritis),  or,  on  the 
other  hand,  of  undue  stretching  and  prolapse  of  the  relaxed 
pelvic  organs.  Women  who  are  predisposed  to  such  an  ac- 
cident should  not  be  allowed  to  lie  on  their  backs  too  long, 
because  that  position  favors  retroversion  and  retroflexion 
of  the  relaxed  uterus.  They  should,  therefore,  be  made 
to  lie  on  their  sides  after  the  fourth  day.  On  the  other 
hand,  women  with  vigorous  and  elastic  tissues  often  lose 
less  blood  and  experience  earlier  involution  of  the  nterus 
if  they  get  up  after  three  or  four  days.  If  a  woman  has 
no  fever  and  is  not  suffering  from  any  kind  of  weakness, 
as  from  hemorrhage,  she  should  not  be  allowed  to  remain 
in  bed  longer  than  twelve  to  fourteen  days  without  a  very 
strong  reason,  as  in  such  a  case  the  protracted  rest  in 
bed  leads  to  undesirable  relaxation  of  the  body,  mani- 
festing itself  at  first  in  sluggishness  of  the  bowels.     Loss 


SVMPTOJIATOLOGY  AXI)  MAXAGEMENT.        131 

of  elasticity  in  the  abdominal  walls,  or  pendulous  ab- 
domen, is  often  an  accompaniment,  although  not  a  conse- 
quence, of  this  condition.  To  guard  against  it  some 
form  of  binder  is  to  be  applied  to  the  abdomen  imme- 
diate! v  after  the  woman  is  delivered  (or  a  folded  bed- 
sheet  "mav  l)e  laid  on  the  abdomen),  and  after  the  third 
day  the  bowels  must  be  emptied  regularlv,  either  by  re- 
minding the  puerpera  to  move  her  bowels  or,  if  necessary,  by 
the  administration  of  enemata.  The  same  attention  should 
be  Q:iven  from  the  very  beginning  to  evacuation  of  the 
bladder.  The  diet  is  to  be  regulated  according  to  the  above 
schedule.  Milk  is  the  best  food,  but  one  must  guard 
ao-ainst  over-feeding.  If  the  abdomen  is  relaxed  and  if 
milk-secretion  is  insufficient,  the  abdomen  should  be  mas- 
saged several  times  daily. 

The  vulva  as  well  as  the  perineal  and  gluteal  regions  are 
to  be  washed  twice  daily  with  warm  water  and  soap,  and 
irrigated  with  boiled  water  or  a  weak  antiseptic  solution, 
the  nymphffi  being  held  apart,  especially  if  any  fissures  or 
excoriations  are  seen  about  the  vaginal  outlet.  On  the 
other  hand,  vaginal  douches  must  be  avoided  after  the 
placenta  has  been  delivered,  in  fact,  the  inner  portions  of 
the  sexual  organs  should  not  be  touched  after  delivery  of 
the  placenta  without  a  very  strong  reason. 

The  second  point  that  should  engage  our  attention  is 
the  general  condition  of  the  puerpera,  as  it  enables  us  to 
judge  whether  infection  of  the  genitalia  has  taken  place 
or  not.  Hence  the  temperature  and  pulse  are  to  be  taken 
everv  morning  and  evening,  the  sensitiveness  of  the 
abdomen  in  ge'neral  and  of  the  uterus  and  adnexse  in  par- 
ticular, as  well  as  of  the  mamma,  is  to  be  investigated, 
and,  finallv,  the  color  and  odor  of  the  lochial  discharges 
should  be*  carefully  noted.  If  fever  makes  its  appear- 
ance (the  relation  between  the  pulse  and  the  temperature 
is  verv  important  in  this  connection  in  the  beginning) 
without  any  other  evident  cause  the  origin  of  the  trouble 
is  to  be  sought  in  the  genitalia.  "Puerperal  fever" 
under  such  conditions  is  ni  almost  every  case  a  sign  of 


132    THE  PUERPERIUM  AND  NEW-BORN  INFANT. 

genital  infection.  So-called  milk-fever,  in  the  ancient 
sense  of  the  term,  does  not  exist.  In  the  relaxed  condi- 
tion of  the  genitalia,  especially  in  marked  anteflexion  of 
the  uterus,  a  fever  due  to  absorption  sometimes  makes  its 
appearance  on  the  third  or  fourth  day  and  lasts  from 
twenty-four  to  forty-eight  hours.  As  soon  as  the  first 
symptoms  of  distress,  such  as  restlessness  and  insomnia, 
make  their  appearance,  it  is  most  important  to  induce 
thorough  diaphoresis,  defecation,  and  diuresis. 

The  woman  should  avoid  all  sudden  movements  when 
she  sits  up  or  gets  up  out  of  bed,  on  account  of  the 
danger  of  pulmonary  embolism  from  a  thrombus  at  the 
placental  site,  especially  after  endometritis.  Such  an 
accident  may  lead  to  the  gravest  complications  and  has 
often  resulted  in  sudden  death.  On  the  other  hand,  it  is 
advisable  to  let  the  puerpera  sit  u})  under  proper  precau- 
tions during  the  first  days,  to  prevent  stagnation  of  the 
lochia  in  the  vagina. 

Lactation  next  demands  our  attention.  I  liave  already 
mentioned  the  desirable  qualities  in  the  motlier  or  nurse 
who  is  to  suckle  the  baby,  as  well  as  the  care  demanded 
by  the  mammary  glands  and  nipples  during  pregnancy. 
When  the  womarx  begins  to  nurse,  the  nipples  and  the 
clothing  with  which  they  come  in  contact  must  be  kept 
scrupulously  clean  to  prevent  the  entrance  of  the  Oidium 
albicans  into  the  infant's  mouth.  The  mother  should  lie 
on  her  side  and  hold  the  child  in  the  liollow  of  her  arm. 
Mother  and  child  must  never  sleep  in  the  same  bed. 
This  caution  is  to  be  strictly  enforced  in  the  case  of 
nurses.  If  the  nipples  are  unfit  for  sucking  and  there  is 
still  a  plentiful  supply  of  good  milk,  a  false  nipple  should 
be  used,  either  one  of  the  old  kind,  made  of  rubber,  or 
one  made  of  glass.  Auvard's  is  the  best  for  weakly 
children,  because  it  permits  the  mother  to  assist  in  draw- 
ing out  the  milk.  All  such  apparatus  must  also  be  kept 
scrupulously  clean.  The  breast  is  to  be  Avashed  after 
every  nursing.  Weakly  or  premature  children  are  to  be 
fed  with  a  spoon,  which  must  also  be  kept  clean. 


SYMPTOMATOLOGY  AND  MANAGEMENT.        133 

If  milk  secretion  is  insufficient,  it  can  he  increased  by 
massage  of  the  relaxed  ahdomen  and  the  application  of  a 
firm  binder,  supplemented  with  a  weight  applied  on  the 
abdomen,  by  the  administration  of  somatose,  and  by  be- 
ginning twelve  hours  after  birth  to  put  the  child  to  the 
breast  regularly. 

Menstruation,  which  occurs  after  six  weeks  in  45  per 
cent,  and  regularly  in  20  per  cent,  of  puerperal  women, 
does  not  affect  either  the  quantity  or  the  quality  of  the 
milk,  provided  the  milk  secretion  is  good.  Even  the  oc- 
currence of  pregnancy  exercises  no  injurious  influence  on 
lactation  in  healthy  mothers,  nor  on  the  development  of 
the  fetus  ;  I  saw  a  case  in  which  a  mother  who  did  not 
know  she  was  pregnant  nursed  her  child  during  the 
first  four  months  of  pregnancy.  The  physician  should 
therefore  be  guided  in  his  advice  by  the  constitution  of 
the  individual.  Nursing  need  not  necessarily  be  forbid- 
den after  the  occurrence  of  pregnancy.  Pregnancy  is 
most  apt  to  occur  when  the  menstrual  period  reappears 
regularly,  that  is  to  say,  in  20  per  cent,  of  all  nursing 
women.  If  on  account  of  inflammatory  conditions  or 
for  any  other  reason  the  child  has  been  weaned,  and  its 
nutrition  is  thereby  very  much  reduced,  it  is  possible  to 
restore  the  milk  secretion  even  after  wTcks  of  inactivity 
by  again  putting  the  child  to  the  breast. 


PART    II. 

Pathology  and  Treatment  of  Preg- 
nancy, Labor,  and  the  Puerperium. 


CHAPTER  V. 


THE   PATHOLOGY    OF    PREGNANCY,    INCLUDING 
ABORTION   AND   PREMATURE   LABOR. 

§  12.  ANOMALIES  WHICH  LEAD  TO  ABORTION. 

By  abortion  is  meant  the  premature  expulsion  of  the 
ovum  before  the  formation  of  the  placenta  is  completed  ; 
that  is  to  say,  before  the  fourth  month  ;  after  that  period 
we  speak  of  premature  birth. 

DIAGNOSIS  AND  TREATMENT  OF  ABORTION. 

The  beginning  of  an  abortion  is  diagnosed  by  the 
bright  red  color  of  the  vulva  and  vaginal  walls,  the 
softening  and  enlargement  of  the  uterus,  especially  in  the 
anteroposterior  diameter,  giving  it  a  balloon-like  shape, 
and  by  the  occurrence  of  persistent  hemorrhage.  In 
some  cases  there  is  a  history  of  preceding  amenorrhea. 

(a)  If  the  external  os  is  closed  the  treatment  must  be 
expectant.  If  the  abortion  is  due  to  an  accident,  such  as 
a  fall,  and  not  to  constitutional  disease,  the  prospect  of 
bringing  the  embryo  to  maturity  is  good,  especially  in 
vigorous  women,  even  without  protracted  rest  in  bed,  as  I 
can  illustrate  by  the  following  case  : 

134 


AXOMALIES   WHICH  LEAD   TO  ABOHTION.       135 

A  hotcl-kcepcr  changed  her  residence  to  another  town  at  a  time 
when  without  knowing  it  she  was  in  her  second  month  of  preg- 
nancy. Before  her  departure  she  fell  from  the  fifth  rung  of  a  ladder 
and  immediately  had  a  fairly  copious  hemorrhage  from  the  geni- 
talia, which  persisted  during  all  the  time  she  was  engaged  in 
packing  and  in  making  the  journey  and  for  three  weeks  afterward, 
at  which  time  the  woman  slipped  as  she  stepped  out  of  the  bath- 
tub and  again  fell  to  the  floor.  The  hemorrhage  became  more 
profuse  and  slight  pains  resembling  labor-pains  made  their  ap- 
pearance. When  I  told  her  my  diagnosis  she  was  very  much 
astonished  to  learn  that  she  was  pregnant.  She  would  not  hear 
of  going  to  bed,  partly  because  she  was  not  quite  convinced  of  her 
pregnancy  and  partly  on  account  of  the  duties  demanded  of  her 
by  her  business.  I  administered  opiates  per  vaginam  and  went 
away  expecting  to  be  called  again.  I  was  not  sent  for  again, 
however,  until  I  was  called  in  to  deliver  a  healthy  and  well- 
developed  boy  at  term.  The  placenta  showed  no  changes.  I  had 
convinced  myself  at  the  time  by  an  examination  with  the  specu- 
lum that  the  hemorrhage  came  from  the  uterus. 

Expectant  treatment  consists  in  ordering  the  patient  to 
bed  for  a  period  not  longer  than  eight  days,  and  in  admin- 
istering opiates  in  bougies,  or  vaginal  douches  of  tepid 
boiled  water  with  the  least  possible  amount  of  pressure. 
If  the  hemorrhage  is  profuse  and  persistent,  cold  irriga- 
tions should  be  given  and  compresses  applied  to  the 
abdomen.  As  a  matter  of  course,  strict  antiseptic  pre- 
cautions mnst  be  observed  in  making  explorations  or 
other  manipulations  so  as  to  minimize  the  danger  of 
infection. 

(6)  If  the  external  os  is  dilated  and  the  tip  of  the  ovum 
projects  into  the  cervical  canal,  we  have  to  deal  with  an 
advanced  abortion  which  cannot  be  averted.  In  such  a 
case  removal  of  the  ovum  is  indicated,  it  being  immaterial 
whether  the  hemorrhage  is  profuse,  as  is  usually  the  case, 
or  slight  (for  technique  see  Atlas  of  Labor  and  Operative 
Obstetrics).  The  cervical  canal  and  vagina  are  packed 
with  tampons  of  sterilized  gauze  (iodoform  or  nosophen) ; 
and  ero^ot,  ergotin,  or  quinine  sulphate  (several  doses  of 
gr.  viij  =0.5  gm.)  are  giveu  by  the  mouth.  If  the  labor- 
pains  are  strong,  tampon  and  ovum  are  expelled  from  the 
uterus.     If,  on  the  other  hand,  labor-pains  cease,  the  ovum 


136      THE  PATHOLOGY  OF  PREGNANCY. 

is  found  behind  the  tampon  and  can  be  easily  removed 
with  the  abortion  foi'ceps.  Complete  expulsion  of  the 
uninjured  ovum  is  not  to  be  expected,  as  a  rule,  after 
the  fourth  month.  Later  than  that  the  amniotic  sac  first 
ruptures ;  this  is  followed  by  the  appearance  of  the  fetus, 
and  finally  the  placenta  comes  away. 

(c)  If  the  product  of  conception  has  already  been  ex- 
pelled, the  cervical  canal  is  found  dilated,  the  body  of  the 
uterus  is  usually  hard  and  contracted  by  the  severe  labor- 
pains,  although  it  may  continue  to  bleed  in  spite  of  the 
pains,  and  the  hemorrhage  will  certainly  recur  as  soon  as 
the  contractions  cease.  Digital  exploration  reveals  a  rough 
surface  with  blood-clots  and  epithelial  shreds,  which  under 
the  microscope  are  seen  to  consist  of  chorionic  villi  and 
decidual  tissue  (see  Figs.  15  and  16). 

If  portions  of  the  membranes  remain  behind,  the  hemor- 
rhage persists,  the  blood  being  mixed  with  brownish 
particles,  which  eventually  give  off  a  fetid  odor.  Under 
these  conditions,  whether  we  have  to  deal  with  a  fresh  case 
accompanied  by  profuse  hemorrhages,  or  septic  infection 
has  occurred  from  the  remains  of  the  fetal  membranes, 
the  uterus  is  to  be  evacuated  by  means  of  bimanual  com- 
pression, or  it  may  be  rapidly  dilated  by  means  of  conical 
metal  dilators  of  various  sizes,  after  Fritsch  and  Hegar. 
If  expression  fails  to  remove  the  placental  remains,  the 
interior  of  the  uterus  must  be  scraped  with  two  fingers  or 
with  a  blunt  curette  (see  Atlas  of  Labor  and  Operative 
Obstetrics). 

In  cases  of  putrid  abortion  the  author  recommends 
vaporization,  but  not  before  the  length  of  the  uterus  has 
been  accurately  determined,  and  only  with  a  heated  in- 
strument— that  is  to  say,  not  directly  w^ith  steam — and 
only  when  it  is  performed  by  a  practised  hand.  These 
procedures  are  to  be  followed  by  irrigation  with  2  per 
cent,  solution  of  carbolic  acid,  packing  of  the  uterus  with 
iodoform  gauze  for  twenty-four  hours,  the  administration 
of  ergotin,  and  rest  in  bed  for  a  week.  If  there  is  fever, 
Priessnitz  compresses  and  mild  laxatives  are  indicated. 


ANOMALIES  WHICH  LEAD  TO  ABORTION.      137 

If  it  is  impossible  to  arrest  the  septic  process,  total  extir- 
pation of  the  organ  may  have  to  be  considered. 

If  portions  of  the  membranes  remain  within  the  uterus, 
they  tend  to  keep  up  the  hemorrhage,  and  the  constant 
deposition  of  fibrin  may  lead  to  their  organization,  so  that 
the  entire  uterine  cavity  may  be  filled  with  a  plastic 
material.  This  process  may  take  place  if  portions  of  the 
placenta  remain  after  the  expulsion  of  an  older,  or  even 
of  a  mature,  ovum.  Such  partial  retention  of  the  placenta 
leads  to  what  is  known  as  "a  placental  polyp.  If  an 
ovum  is  expelled  or  removed  in  toto,  the  uterus  need  not 
be  curetted,  as  any  remaining  portions  of  the  decidua  do 
not  in  the  least  interfere  with  the  regeneration  of  the 
mucous  membrane.  Tamponade  is  required  only  after 
hemorrhages,  or  after  curettage  of  the  uterus  performed 
for  the  purpose  of  removing  larger  adherent  portions  of 
the  membrane.  If  the  temperature  rises,  the  tampon  is 
to  be  at  once  removed.  The  mechanism  of  the  separation 
of  an  aborted  ovum  is  the  same  as  that  of  an  older 
placenta  (see  Fig.  11  in  the  text).  A  retroplacental  he- 
matoma forms  usually  at  the  edge  of  the  insertion  of  the 
ovum  in  the  decidua  vera,  and  separation  begins  either  at 
the  margin  or  at  the  central  portion  of  the  insertion.  In 
the  former  case  a  part  of  the  ovum  nearest  the  true  mater- 
nal area  of  separation  first  appears  in  the  cervical  canal. 
In  the  latter  case  the  villous  decidua  reflexa  is  the  first  to 
appear.  If  in  the  latter  mode  of  separation  the  fetal 
membranes  rupture,  the  ovum  is,  of  course,  expelled  first, 
and  the  free  portions  of  the  fetal  membranes  become 
wrapped  about  the  massive  portion  of  the  ovum  toward 
the  fundus;  in  other  words,  the  fetal  surface  of  the 
amniotic  sac  prolapses. 

If  the  embryo  is  retained  in  the  uterine  cavity,  it  be- 
comes macerated  and  then  undergoes  absorption.  The 
fetus  may  undergo  mummification  (fetus  papyraceus),  but 
on  the  admittance  of  air  or  pathogenic  organisms  putrefac- 
tion takes  place.     Thus  the  fetus  may  be  retained  in  utero 


138  THE  PATHOLOGY  OF  PREGNANCY. 

beyond  the  physiological  duration  of  pregnancy  (missed 
abortion). 

Lithopedia,  which  are  sometimes  found  in  the  uterus, 
are  probably  derived  from  tubal  or  other  extra-uterine 
pregnancies,  or  from  amniotic  sacs  within  rudimentary 
cornua. 

The  treatment  does  not,  as  a  rule,  end  with  the  removal 
of  the  ovum,  because  the  causes  of  abortion,  which  are 
too  often  regarded  as  its  consequences,  still  persist.  As 
a  rule,  they  consist  in  inflammatory  conditions  of  the  mater- 
nal or  fetal  membranes,  or  in  general  constitutional  diseases 
such  as  syphilis  or  perhaps  tuberculosis,  which  find  their 
local  expression  at  this  point,  or  in  acute  febrile  infectious 
diseases  or  in  excessive  physical  or  mental  excitement 
(circulatory  disturbances),  or,  finally,  in  displacements  and 
tumors  in  the  various  portions  of  the  genital  tract. 

Accordingly,  we  observe  after  an  abortion  persistence 
of  the  congestion  and  chronic  inflammations,  catarrhal 
hypersecretion,  menorrhagia,  displacements  of  the  uterus, 
either  by  a  flexion  of  the  imperfectly  involuted  walls  or 
by  adhesions. 

One  abortion  predisposes  to  others,  hence  in  a  succeeding  preg- 
nancy preventive  measures  are  indicated.  One  of  my  patients 
had  four  abortions  folh)wing  four  normal  pregnancies.  In  the 
fourth  month  of  her  ninth  pregnancy  I  found  a  perineal  tear  of 
the  second  degree,  inversion  of  the  interior  vaginal  wall  w^ith  a 
cystocele,  and  a  deep  ulceration  of  the  external  os  with  marked 
ectropion  of  the  cervical  mucous  membrane.  I  applied  a  Mayer 
ring-pessary  and  pregnancy  went  on  to  term,  although  hemorrhages 
had  already  occurred. 

In  another  case  in  which  there  were  hemorrhages  in  the  sixth 
month  of  pregnancy,  the  woman  having  previously  had  an  abor- 
tion, the  hemorrhages  were  controlled  by  invigorating  measures 
(iron,  massage)  and  by  the  use  of  vaginal  irrigations  with  luke- 
warm emollient  solutions. 

The  morbid  anatomy  of  the  aborted  ovum  varies  with 
the  cause  of  its  expulsion. 

(1)  Sub  chorionic,  that  is  to  say,  decidual  hemorrhages, 
are  apt  to  form  in  general  infectious  diseases,  especially 
acute  diseases  attended  with   high  temperature   (typhus. 


ANOMALIES   WHICH  LEAD  TO  ABORTION.       139 

cholera,  variola,  influenza),  and,  by  interfering  with  the 
circulation  and  possibly  by  the  transmission  of  toxins, 
bring  about  the  death  of  tlie  fetus.  Direct  infection,  on 
the  other  hand,  by  the  transmission  of  pathogenic  micro- 
organisms to  the  fetus,  which  has  been  proven  experi- 
mentally and  clinically  (pockmarks  in  the  new-born 
infant),  may  be  survived. 

These  hemorrhages  into  the  decidua  (most  frequently  into  the 
serotina)  are  found  either  in  the  stroma,  when' thev  force  the 
fibers  and  large  decidual  cells  apart,  or  in  the  gland-follicles,  or 
in  preformed  invaginations  of  the  fetal  membranes  which  continue 
to  grow  after  the  death  of  the  fetus— the  so-called  hematoma 
moles  described  by  Breus.  They  produce  nodes  the  size  of  a 
hazelnut  in  the  fetal  membranes,  and  these,  in  addition  to  infect- 
ing the  fetus,  may  lead  to  malformations  bv  their  interference 
with  the  fetal  movements  (Figs.  88,  91,  and  92;  Fig.  11  in  the 
text). 

These  hemorrhages  usually  bring  on  an  abortion  before 
the  fourth  month.  As  a  rule,  the  embryo  undergoes  ab- 
sorption— the  amniotic  fluid  is  turbid  and  brownish  in 
color,  remains  of  the  umbilical  cord  and  of  the  allantoid 
ve-icle  are  seen — or  the  fetus  dies  as  the  result  of  torsion 
of  the  cord  and  undergoes  maceration.  The  ovum  may 
continue  to  grow  by  itself. 

In  other  cases  a  lymphoid  exudation  separates  the 
amnion,  and  the  ovum  may  be  expelled  either  in  its  own 
fetal  membranes,  that  is,  the  chorion  and  amnion,  or  in 
the  intact  amniotic  sac  alone  (Fig.  12  in  the  text).  Ex- 
pulsion with  the  maternal  decidua,  that  is,  with  a  com- 
plete cast  of  the  uterine  body  in  the  form  of  detached 
decidua  vera,  is  illustrated  in  Figs.  67,  a,  and  67,  6  ;  we 
see  that  the  ovum  in  the  first  and  second  month  is  smaller 
than  the  uterine  cavity  (Figs.  17  and  18),  showing  that 
the  latter  is  growing  actively. 

Cf.  Fig.  67,  a.  DHangular  Piece  of  Decidua  Vera  Expelled  in  an 
Extra-uterine  Pregnancy. — The  external  surface  is  rough,  the  in- 
ternal surface  shows  the  mouths  of  ducts  and  numerous  plications. 

Fig.  67,  b.  The  Same. — In  this  case  the  decidua  vera  has  formed 
below  the  internal  os  in  an  expanded  portion  of  the  cervix,  an 


140  THE  PATHOLOGY  OF  PREGNANCY. 

Plate  36. 

Fig.  81.  Necrotic  Decidua  of  a  Hematoma  Mole  Retained  in  utero, 
so-called  missed  abortion  (original  water-color,  natural  size,  from  the 
author's  own  case). 

Plate  38. 

Fig.  88.  Mummified  Fetus  with  Retained  Abortive  Ovum  (belonging 
to  Fig.  81). — The  ovum  grew  with  the  fetus  until  the  third  month,  after 
which  time  amenorrhea  continued  ten  months  longer.  Thus,  after  an 
interval  of  thirteen  months,  the  menstrual  flow  reappeared  with  great 
pain,  portions  of  the  necrotic  decidua  serotina  being  discharged  at  each 
period.  The  ovum  itself,  however,  was  retained  two  months  longer, 
when  it  was  finally  expelled  with  labor-pains  and  a  moderately  copious 
menstrual  flow.  The  decidua  (Fig.  81)  was  also  necrotic.  The  rest  was 
filled  with  coagulated  hematomata.  so  that  the  chorion  bulged  into  the 
amniotic  sac  (Fig.  88).  Hematomata  are  also  seen  on  the  maternal  sur- 
face. The  amniotic  sac  is  filled  with  dry  masses  of  clotted  blood,  the 
remains  of  which  can  be  seen  in  the  illustration  as  reddish  nodules 
covering  the  irregular  amnion  and  depriving  it  of  its  luster.  The 
amniotic  fluid  was  entirely  absorbed.  The  fetus  measured  about  3J  in. 
(8  cm.)  in  length,  was  much  deformed,  and  showed  signs  of  an  inflam- 
matory process  which  had  evidently  made  its  appearance  late.  The  left 
foot  had  grown  fast  to  the  right  leg. 

In  the  Munich  Gynecological  Clinic  there  is  a  fetus  which  presents 
similar  abnormalities.  In  this  case  the  umbilical  cord  passes  through 
the  femoral  ring,  a  proof  of  the  late  development  of  the  condition.  The 
right  eye  and  the  nose  were  covered  over  with  membranous  bands,  the 
flngers  and  toes  were  grown  together,  the  body  was  mummified,  the 
umbilical  cord  twisted,  the  torsion  being  greatest  at  the  abdominal  ex- 
tremity. Missed  abortion  takes  place  when  the  fetus  and  chorion  grad- 
ually die,  as  in  chronic  disease  of  both  parents. 

Plate  39. 

Fig.  89.  Hydatid  Mole  (original  water-color). — Some  normal  placental 
tissue  is  seen  between  the  cystic  myxomatous  chorionic  villi  on  the  ex- 
ternal surface.  The  color  of  the  surface  of  the  villi  corresponds  to  their 
degree  of  vascularization.  A  few  of  the  cysts  are  attached  to  pedicles 
formed  of  chorionic  villi.  A  large  percentage  of  the  placenta  was  normal 
and  had  sufficed  for  the  nutrition  of  a  well-formed  fetus  which  was  born 
prematurely.  The  free  membranes  and  the  amniotic  cavity  show  noth- 
ing abnormal. 

exceptional  condition  of  affairs.     (Both  original  drawings  after 
preparations  at  the  Munich  Gynecological  Clinic.) 

After  the  fifth  month  the  amniotic  fluid  is,  as  a  rule, 


Tab.  39. 


^r^^bw 


^ 


Fig.  89 


,rhh,.lil     Mrinrh, 


ANOMALIES   WHICH  LEAD   TO  ABORTION.       141 


discharged  before  the  expulsion  of  the  ovum  takes  place ; 
hence  a  perfectly  preserved  ovum  from  this  period  on  is 
very  rare.     In  Plate  5,  Fig.  12,  a  three-months'  ovum  is 


D.V 


yi.RI-BN. 


ChJianf. 


Am.. 


CH 


^~  Nab. 

\% 

in 

i 

^ 

'1 
1 

1 

t 

1 

■  1     ; 

,  "  j- 

6 

■^ij 

Fig.  11.— Beginning  abortion  after  subchorionic  decidual  hemorrhage 
{Ch.  Ham.),  partly  seen  through  the  amniotic  sac  (Am.)  and  partly  cut 
through.  The  largest  hemorrhage  is  in  thedecidua  vera  {R.  Ham.),  and 
represents  a  kind  of  retroplacental  hematoma,  which  increases  as  the 
ovum  separates.  The  umbilical  cord  (Nab.)  of  the  fetus  is  twisted,  its 
insertion  corresponds  with  the  blood-clot,  and  thus  leads  to  circulatory 
and  respiratory  disturbances  which  result  in  excessive  twisting  of  the 
cord.     The  decidua  vera  (D.  v.)  extends  to  the  internal  os. 

seen  artificially  opened ;  the  decidua  reflexa  is  torn  into 
shreds  and  can  easily  be  distinguished  from  the  chorion 
(see  also  Fig.  8).     In  Fig.  13  is  seen  a  completely  de- 


142  THE  PATHOLOGY  OF  PREGNANCY. 

Plate  40. 

Fig.  90.  Decidual  Endometritis  (original  drawing)  :  1,  dilated  gland- 
follicles  with  desquamated  epithelium;  in  hypersecretion  these  glands 
discharge  their  contents  (as  shown  in  numerals  9  and  10)  between  the 
decidua  reflexa  and  the  decidua  vera  into  the  free  lumen  of  the  uterus — 
hydrorrhea  gravidarum  ;  2,  chorionic  villi  embedded  in  partially  disinte- 
grated decidual  tissue  (3) ;  4,  intact  chorionic  villi  lying  in  the  free 
intervillous  spaces  (filled  with  maternal  serum  or  blood),  either  in  close 
apposition  or  adherent  to  the  decidua  vera;  5,  small  vascular  villi 
branching  from  a  large  attachment-villus  (6),  the  latter  gradually 
merges  into  decidual  tissue ;  7,  capillary  vessels  in  the  inflamed  inter- 
stitial portion  (3  and  9)  very  much  dilated  (not  so  much  as  a  result  of 
the  inflammation  as  of  pregnancy)  ;  8,  glandular  endometritis ;  9,  inter- 
stitial endometritis  with  areas  of  round-celled  and  leukocytic  infiltra- 
tion ;  10,  decidua  reflexa  merging  into  decidua  vera ;  11,  a  gland  with 
intact  cylindrical  epithelium  from  that  part  of  the  uterine  cavity  which 
is  not  filled  with  the  ovum,  although  forming  a  part  of  the  decidua 
vera ;  12,  hypertrophied  decidual  tissue  forming  polypoid  or  bridge-like 
excrescences,  and  showing  a  telangiectactic  tendency  (7).  (For  the 
chorionic  villi,  cf.  Figs.  16  and  91.) 

Plate  41. 

Fig.  91.  Subchorionic,  that  is,  Decidual  Hemorrhage  (original  draw- 
ing from  the  author's  own  microscopical  preparation) ;  1,  papilla  of 
decidua  vera  ;  2,  extravasation  in  the  decidual  tissue,  forcing  the  fibers 
of  the  stroma  apart  at  3;  4,  thrombus  of  the  intervillous  space  with 
normal  chorionic  villi  (5)  lying  in  juxtaposition  with  the  decidua  vera. 
According  to  the  latest  investigations  the  chorionic  villi  are  not  covered 
with  cuboidal  epithelium  as  was  formerly  supposed,  but  with  a  layer  of 
protoplasm  through  which  nuclei  are  scattered. 

Plate  41. 

Fig.  92.  Subamniotic  so-called  "Fibrin,"  witli  Cysts  and  Extrav- 
asation (original  drawing  from  the  author's  own  microscopical  prepa- 
ration):  1,  single  layer  of  cuboidal  amniotic  epithelium;  2,  connective 
tissue;  3,  so-called  chorion  cells,  partly  degenerated  and  converted  into 
fibrin-like  masses  with  parallel  fibers  as  the  efl'ect  of  amniotic  and  intra- 
uterine pressure  (4) ;  0,  homogeneous  masses  consisting  of  necrotic  villi ; 
6,  serous  cysts  Mnthout  any  protoplasmic  investment  (8),  sanguineous 
cysts  (6  and  8)  lying  within  the  degenerated  masses  of  cells  ;  7,  accumu- 
lations of  round  cells  ;  9,  intervillous  thrombus  in  the  neighborhood  of 
the  necrotic  villi  (11),  which  have  run  together  by  necrosis  of  their 
protoplasmic  covering  (12)  ;  10,  normal  vascular  villi ;  13,  decidual 
papilla  with  large  capillary  blood  space  (14)  and  gland  (15). 


Tab.  40. 


Fig.  90. 


LiJth.  Arist  E  ReidUwld,  Mdndien. 


Tab.  41. 


-/ —  iamv!^^'^"'<i*i'imt,t^ 


Fig.  91. 


^1  <^f--£i^->^-«,;-^^<- 


Fig.  92. 


Z«yi.  ^«.5?  F.  Rachhold,  Miindien. 


ANOMALIES  WHICH  LEAD  TO  ABORTION.       143 


veloped  placenta  serotina  and  the  torn  chorionic  mem- 
brane, which  has  undergone  invokition  and  has  become 
united  with  the  decidua  reflexa,  and  finally,  the  amnion 
of  a  four-months'  ovum.     In  rare  instances  the  fetus  may 


Fig.  12. — Intact  amniotic  sac  {Am.)  expelled  in  the  premature  delivery 
of  a  seven-months'  fetus.  Above  we  see  a  fragment  of  detached  chorion 
{Ch.),  to  the  left  the  insertion  of  the  cord  {Nab.)  where  it  has  been  torn 
away  from  the  serotina.  In  most  cases  a  fetus  of  this  kind  shows  path- 
ological changes  of  some  duration  (original  drawing  from  a  preparation 
at  the  Munich  Gynecological  Clinic). 

be  expelled  with  the  amniotic  sac  intact,  the  latter  sepa- 
rating from  the  chorion,  and  the  umbilical  cord  becoming 
severed  from  the  chorionic  membrane  (Fig.  12  in  the 
text). 

The  term  blood-moles  is  applied  to  retained  decidua 


144      THE  PATHOLOGY  OF  PREGNANCY. 

when  it  becomes  hemorrhagic  and  is  subsequently  expelled 
separately. 

Special  pathological  forms  of  abortion  are  produced 
either  by  inflammations  of  the  endometrium  or  by  general 
diseases,  such  as  syphilis  and  eclampsia. 

Two  kinds  of  inflammation  of  the  uterine  mucosa  are  distin- 
guished, that  of  the  glandular  portion  and  that  of  the  connective- 
tissue  stroma,  termed,  respectively,  endometritis  glandularis  and 
interstitialis.  The  etiology  of  the  two  varieties  is  the  same.  Both 
may  arise  from  chronic  hyperemia,  that  is  to  say,  from  circulatory 
disturbances  of  a  non-infectious  origin  or  from  infection  (gonorrhea- 
tuberculosis,  sepsis). 

Such  forms  of  endometritis,  though  comparatively  fre- 
quent, rarely  lead  to  abortion  or  any  special  alteration  of 
the  fetal  membranes ;  but  the  inflammatory  process  is 
certainly  not  relieved  by  pregnancy. 

In  rare  cases  it  has  been  possible  to  demonstrate  intercellular 
diplococci  or  bacteria  in  the  fetal  membranes.  At  the  same  time 
numerous  foci  of  round-celled  infiltrations  surrounded  by  extensive 
hemorrhages  were  found  in  the  decidua  vera.  The  products  of 
inflammation  were  also  seen  in  the  decidua  serotina  near  the  sur- 
face, in  the  form  of  aggregations  of  round-celled  infiltration  with 
a  central  necrotic  area. 

Another  variety  of  fetal  disease  due  to  endometritis 
catarrhalis  deciduce  verce   is  known    symptomatically    as 

(2)  Hydrorrhoea  uteri  gravidi,  and  in  this  simple  form 
rarely  leads  to  abortion.  As  a  result  of  hypersecretion 
of  the  hypertrophied  and  hyperplastic  glands  the  decidua 
reflexa  separates  from  the  decidua  vera  and  the  secretion, 
which  may  exceed  3  fl.  oz.  (100  gm.)  at  each  evacuation, 
is  discharged  from  the  internal  os  by  uterine  contrac- 
tions resembling  labor-pains.  It  is  distinguished  from 
the  amniotic  fluid  by  the  fact  that  it  is  not  followed  by 
premature  birth  and  does  not  contain  either  vernix  caseosa 
or  lanugo  hairs.  From  urine  it  is  distinguished  by  the 
fact  that  it  contains  no  urea  or  only  very  minute  quanti- 
ties, that  it  is  neutral  or  alkaline  in  reaction,  and,  finally, 
by  the  fact  that  it  evidently  emanates  directly  from  the 


ANOMALIES   WHICH  LEAD   TO  ABORTION.       145 

uterus.  It  is  distinguished  from  the  secretion  of  a  sim- 
ple cervical  endometritis  and  colpitis  by  the  fact  that  the 
latter  is  very  much  less  in  quantity  and  contains  pus- 
corpuscles  and  fungi,  whereas  the  secretion  of  hydrorrhea 
uteri  gravidi  is  of  a  watery  and  glairy  nature  (rarely 
containing  a  small  amount  of  blood  or  pus  when  combined 
Avith  cervical  endometritis),  free  from  albumin,  contains  a 
large  percentage  of  NaCl,  carries  a  number  of  epithelial 
elements  along  with  it,  and  has  a  specific  gravity  of  1003. 
The  secretion  collects  between  the  two  deciduse,  or, 
owing  to  the  permeability  of  the  fetal  membranes  for 
amniotic  fluid,  may  be  found  between  the  decidua  reflexa 
and  the  chorion,  or  between  the  latter  and  the  amnion. 
If  the  secretion  is  retained  within  the  gland-spaces  the 
condition  is  known  as  endometritis  decidualis  cystica 
(Fig.  90) ;  if  the  inflamed  and  hyper23lastic  mucosa  un- 
dergoes proliferation  a  third  pathological  condition  of  the 
ovum  is  produced,  known  as 

(3)  Decidua  Polyposa. — Proliferation  of  the  stroma  and 
of  the  cellular  elements  progresses  pari  passu,  and  leads 
to  the  formation  of  polypoid  excrescences  consisting  of 
fibrous  tissue  harboring  large  deciduous  cells,  which  in- 
duce circulatory  disturbances  in  the  form  of  engorgement 
of  individual  dilated  vessels  and  of  the  cavernous  blood 
spaces  (see  Fig.  90,  ^o.  12).  Later  copious  extravasa- 
tions form,  of  which  the  polypoid  excrescences  ultimately 
appear  to  consist. 

On  the  other  hand,  there  may  be  a  defective  formation 
of  decidua  vera,  an  atrophy,  in  other  words,  cell  pro- 
liferation being  absent  and  the  newly  formed  cells  un- 
dergoing fatty  degeneration.  The  atrophic  decidua  is 
smooth. 

3Iyxoma  ckorii  multiplex  is  a  nutritive  disturbance  of 
the  chorionic  villi,  which  in  some  cases  appears  to  originate 
in  the  decidual  elements — formerly  it  was  attributed  ex- 
clusively to  the  fetal  tissues  of  the  chorionic  villi — this 
condition  leads  to  the  formation  of 

(4)  Hydatid  moles  (Fig.  89). 

10 


146      THE  PATHOLOGY  OF  PREGNANCY. 

The  histolopcal  changes  consist  in  proliferation  of  the  syncyt- 
ium and  secretion  of  mucus  in  the  connective  tissue  of  the  villi, 
which  become  edematous  and  undergo  myxomatous  change.  The 
connective  tissue  with  its  contained  vessels  eventually  degenerates. 
Sometimes  Langhans'  layer  proliferates.  During  the  later 
months  the  decidua  is  destroyed,  and  in  malignant  cases  the 
proliferated  syncytium  invades  the  muscular  layer  and  the  blood- 
vessels of  the  uterus. 

The  condition  may  also  be  due  to  local  inflammations 
of  the  endometrium  or  perhaps  to  infectious  diseases  on  the 
part  of  the  mother,  or  to  disease  of  the  ovum  derived  from 
the  father ;  abortion  usually  results.  Sometimes  the  mole 
remains  either  wholly  or  in  part  within  the  uterine  wall 
after  expulsion  of  the  ovum,  undergoes  further  develop- 
ment, and  takes  the  form  of  destructive  myxoma,  reach- 
ing the  pampiniform  plexus  and  sending  metastatic 
emboli  as  far  as  the  pulmonary  artery.  In  other  words, 
these  hydatid  moles  behave  like  malignant  tumors. 

Infective  emboli  from  a  hydatid  mole  retained  in 
utero,  as,  for  instance,  the  malignant  bleeding  nodules  in 
the  vagina  in  Schauta's  case,  are  very  rare,  but  their 
recognition  is  of  great  importance.  In  the  case  men- 
tioned, the  attending  physician  had  treated  the  patient 
for  varix.  In  some  cases  the  nature  of  the  mole  itself 
indicates  the  prognosis  :  the  more  the  syncytium  betw^een 
the  individual  cysts  is  degenerated  the  better  the  outlook, 
and  the  stronger  the  proliferation,  the  more  malignant  the 
process. 

The  destructive  process  begins  in  the  syncytium  and  the  pro- 
liferation is,  therefore,  to  be  regarded  as  an  epifhelioma  of  the 
chorion  (Marchand).  There  is  a  group  of  cases,  however,  which 
present  a  sarcomatous  character,  and  these  should  be  designated 
as  malignant  deciduomata  (Sanger)  or  as  sarcoma  deciduocellulare, 
depending  on  the  preponderance  of  the  chorionic  or  of  the  de- 
cidual tissues. 

Accordingly,  active  therapeutic  measures  are  indicated. 
Abortion  should  be  induced  as  rapidly  as  possible  by  ex- 
citing and  keeping  up  the  labor-pains,  whether  there  is 
any  hemorrhage  or  not — by  tamponage,  dilatation  of  the 


ANOMALIES  WHICH  LEAD   TO  ABORTION.       147 

cervix,  evacuation  of  the  uterus  with  the  hand  or  with  a 
blunt  curette.  The  latter  requires  caution  on  account  of 
the  friable  condition  of  the  w^alls. 

The  diagnosis  is  based  on  the  appearance  of  a  thin 
bloody  discharge  in  the  first  months,  and  on  the  appear- 
ance, toward  the  middle  of  pregnancy,  of  uterine  con- 
tractions and  frequent  hemorrhages.  On  examination  the 
uterus  is  found  to  be  undergoing  rapid  growth  while 
remaining  unusually  soft,  and  without  the  appearance  of 
any  fetal  parts  during  the  second  half  of  pregnancy. 

Once  abortion  has  begun,  the  appearance  of  the  char- 
acteristic cysts  (Fig.  89)  is  an  indication  to  effect  the  com- 
plete evacuation  of  the  uterine  cavity. 

After  the  abortion  has  terminated  the  patient  must 
continue  under  medical  supervision  for  months.  Repeated 
irregular  and  copious  hemorrhages  point  to  a  malignant 
character  of  the  hydatid  mole.  In  such  a  case  the  uterus 
should  be  curetted  for  the  purpose  of  examination,  and 
if  the  result  is  positive,  immediate  extirpation  of  the 
uterus  is  indicated,  but  without  any  further  curettage. 
The  tissue  consists  of  a  mixture  of  structureless  syncytium 
containing  large  nuclei,  giant-cells,  and  insular  accumu- 
lations of  smaller,  less  intensely  staining  ectodermal  cells 
derived  from  Langhans'  layer. 

Just  as  the  myxoma  may  involve  only  a  part  of  the 
placenta,  so  we  may  have  a  general  or  circumscribed 
gelatinous  hyperplasia  of  the  umbilical  cord,  resulting  in 
the  so-called  edematous  form  of  hydatid.  Sometimes  the 
increase  in  the  amniotic  fluid  leads  to  another  anomaly  of 
the  ovum,  known  as 

(5)  Polyhydramnion,  w^hieh  does  not  in  itself  cause 
abortion,  but  may  interrupt  pregnancy,  especially  a 
double  pregnancy,  between  the  fifth  and  seventh  months. 

Hydramnion  is  observed  particularly  in  multiparse  and 
with  chronic  diseases  of  the  mother  (syphilis,  chronic 
anemia  and  relaxed  condition  of  the  system,  leukemia  and 
diabetes),  but  cannot  in  every  case  be  referred  to  any 
definite  symptoms  of   the    mother,    placenta,    or    child, 


148      THE  PATHOLOGY  OF  PREGNANCY. 

although  it  may  occur  in  combination  with  such  symp- 
toms. Sometimes  the  process  runs  an  acute  course  and 
threatens  the  life  of  the  fetus.  Acute  onset  has  been  ob- 
served after  traumatism. 

In  most  cases  polyhydramnion  goes  hand-in-hand  with 
diseases  of  the  fetus,  such  as  edema,  ascites,  and  anasarca 
in  syphilis,  and  in  hydrocephalic  or  transudative  proc- 
esses the  result  of  venous  stasis,  resulting  either  in  hyper- 
secretion of  the  kidneys  or  in  stasis  of  the  umbilical 
veins  and  transudation  through  the  amniotic  lymphatic 
system  into  the  amniotic  sac.  Hence  hydramnion  may 
be  due  to  velamentous  insertion  of  the  cord,  and  some- 
times may  accompany  ectopic  gestation.  Finally,  it  may 
be  produced  by  inflammatory  processes  in  the  fetus  (syph- 
ilis in  a  few  cases  certainly),  directly  as  an  inflammatory 
exudate,  indirectly  as  the  result  of  stasis  due  to  cirrhosis 
of  the  liver,  phlebitis,  and  so  on.  The  presence  of  a 
lymphagogue  substance  has  been  experimentally  proven 
in  a  diseased  ovum  (Opitz).  The  author  has  seen  two 
cases  of  twin  pregnancy  with  acute  hydramnion  in  which 
the  fathers  suffered  with  latent  gonorrhea  and  infected 
their  young  wives ;  later  epididymitis  developed,  and 
although  the  microscopical  examination  of  the  semen 
showed  it  to  be  apparently  healthy,  the  marriages  con- 
tinued sterile.  The  women  showed  no  further  patholog- 
ical changes. 

Owing  to  the  unequal  division  of  the  placental  vascular 
system  in  twins  (Schatz),  the  nutrition  is  unequal,  and  the 
resistance  to  the  current  varies  in  the  so-called  third  pla- 
cental circulation  which  unites  the  two  others.  Hence 
poly-  and  oligohydramnion  (Fig.  100),  and  in  triplets, 
for  instance,  hydramnion  of  two  amniotic  sacs  may 
occur. 

The  diagnosis  finds  some  assistance  in  the  marked 
spherical  shape  of  the  uterus  with  unusual  distention  of 
the  abdomen  (see  Fig.  127,  showing  excessive  distention 
of  the  abdomen  in  the  fifth  month  of  pregnancy),  out  of 
all  proportion  to  the  duration  of  pregnancy,  so  that  often 


ANOMALIES    WHICH  LEAD   TO  ABORTION.       149 

as  early  as  the  fifth  or  sixth  month  the  pressure  may  in- 
terfere with  respiration.  The  fetal  parts  are  difficult  to 
palpate,  especially  as  the  fetus  is  usually  underdeveloped. 
It  is  a  remarkable  fact  that  in  spite  of  the  tension  in  the 
uterine  cavity  the  presenting  portion  of  the  amniotic  sac 
is  relaxed. 

Treatment. — If  the  subjective  symptoms  become  very 
marked  and  dyspnea  sets  in,  puncture  of  the  amniotic 
sac  throuo^h  the  internal  os  is  indicated — never  throuo^h 
the  abdominal  walls.  This  procedure  may  be  repeated, 
and  is  not  by  any  means  always  followed  by  premature 
delivery.  In  some  cases  nature  herself  brings  about  re- 
lief in  this  way. 

Inflammations  affecting  all  the  structural  parts  of  the 
placenta  may  be  diffuse  or  circumscribed. 

(6)  This  inflammation  of  the  placenta  evidently  derives 
its  origin  from  infectious  germs  of  various  kinds,  the 
development  of  which  is  exceedingly  slow.  Syphilis  ini- 
doubtedly  plays  a  part  in  the  etiology,  although  it  may 
not  be  possible  to  demonstrate  it  in  every  case.  The  con- 
dition known  as  eclampsia,  which  manifests  itself  in  clonic 
convulsions  attended  with  loss  of  consciousness,  leads  to 
analogous  changes  in  the  placenta,  especially  to  the  so- 
called  placental  infarcts  which  occur  very  frequently,  but 
cannot  in  any  sense  be  regarded  as  pathognomonic  of 
eclampsia.  A  placental  infarct  consists  in  subamniotic 
necrotic  foci  which,  on  account  of  their  lamellar  structure, 
have  been  designated  "  subamniotic  fibrin. '^  They  often 
occur  in  combination  with  subamniotic  serous  or  sanguin- 
eous cysts. 

Syphilis  leads  to  inflammatory  proliferation  of  the  stroma 
and  protoplasmic  covering  of  the  villi,  with  thickening 
of  the  walls  of  the  blood-vessels  contained  in  them  and 
in  the  umbilical  cord,  which  eventually  becomes  obliter- 
ated. 

These  conditions  tend  to  interfere  w'ith  the  circulation 
of  the  fetus  by  necrotic  separation  of  large  portions  of  the 
placenta,  by  the  formation  of  individual  thrombi  in  the 


150      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  93.  Syphilitic  Inflammatory  Villi ;  marked  prolifevatiou  of  the 
connective-tissue  and  round-cell  infiltration  (5),  especially  in  the 
neighborhood  of  the  thickened  blood-vessels  (1).  A  few  of  the  villi 
have  lost  their  protoplasmic  investment  and  are  in  process  of  conversion 
into  intervillous  thrombi  (3) ;  6,  normal  protoplasm  containing  nuclei 
(cf.  in  this  respect  my  remarks  on  Fig.  16)  ;  7,  villous  blood-vessels — 
healthy,  belonging  to  the  fetus— (original  microscopical  drawing). 

Fig.  94.  Transverse  Section  of  a  Syphilitic  Umbilical  Cord  with  In- 
flammation of  the  Media  and  Adventitia. — Eound-cell  infiltration  con- 
taining a  central  focus  of  softening  (3) ;  the  other  thickened  arteiy  (2) 
shows  the  characteristic  triangular  stellate  form  of  the  intima,  the  thick 
elastic  fibers  of  the  media,  and  the  broad  adventitia.  The  vein  (1)  has 
thin  walls  and  gapes  widely.  The  stroma  is  formed  by  normal  myxo- 
matous connective  tissue  (4).  Externally  the  umbilical  cord  is  invested 
with  amnion,  that  is  to  say,  with  a  layer  of  cuboidal  cells,  5  (original 
microscopical  drawing). 

Fig.  95.  Microscopical  Image  of  a  "Placental  Infarct "  (original  draw- 
ing after  a  series  of  the  author's  own  preparation,  representing  the 
histological  development  of  such  foci) :  1,  decidua  papillee  in  the  chori- 
onic placenta ;  2,  a  robust  connective-tissue  villus  in  the  decidual  tissue 
conveying  fetal  blood-vessels;  3,  normal  villi  containing  fetal  blood- 
vessels within  the  intervillous  spaces,  normally  filled  with  maternal 
blood;  here  we  plainly  see  the  protoplasmic  covering  with  nuclei  scat- 
tered through  it;  4,  decidual  cells  separated  from  each  other  by  exuda- 
tion and  undergoing  necrosis;  5,  necrotic  villi  lying  in  degenerated 
decidual  papillse,  which  have  become  converted  into  laminated  masses 
of  fibrous  tissue  (these  layers  [6]  are  the  result  of  the  varying  pressure 
of  the  uterus  on  the  ovum)  ;  7,  degenerated  chorionic  villi  still  retaining 
a  trace  of  nuclear  stain  in  the  nuclei  of  the  spindle-cells  fused  together 
by  homogeneous  masses  of  cell  debris,  formed  by  the  fusion  of  the  ne- 
crotic nucleated  protoplasmic  covering  of  the  villi  with  secondary  inter- 
villous thrombi ;  8,  the  necrotic  cellular  debris  is  undergoing  organization  ; 
9,  a  broad  zone  of  connective  tissue  rich  in  cells  is  then  formed  ;  10, 
fibrinous  intervillous  thrombus ;  11,  intervillous  thrombus  which  has  not 
yet  undergone  coagulation  ;  12,  villus  in  the  first  stage  of  necrobiotic 
homogeneous  coloration  of  the  pi'otoplasmic  covering.  The  connective- 
tissue  stroma  of  the  villus  is  intact;  13,  villus  in  the  second  stage  of 
degeneration  ;  the  covering  is  changed  to  a  feebly  staining,  homogeneous, 
granular  mass  of  debris,  which  becomes  fused  with  that  of  the  adjoining 
villus;  the  walls  of  the  blood-vessels  are  thickened  in  places  where  the 
stroma  of  the  villi  begins  to  degenerate;  14,  calcareous  deposits;  15, 
minute  cysts  within  the  berry-like  proliferations  of  the  protoplasmic 
covering  (16),  wiiich  at  this  point  is  peculiarly  rich  in  cells ;  17,  deposits 
of  calcified  material  within  these  cysts. 

maternal  blood  spaces,  or  by  diminution  of  the  fetal  pla- 


Tab.  42. 


Fig.  94. 


Lith..Ansi  E  ReichJwld,  Mu/idim. 


CO 
08 

H 


3^ 


^     ^     ^ 


ANOMALIES   WHICH  LEAD   TO  ABORTION.       151 

cental  circulation.  In  addition  to  this  the  condition 
proiluces  active  fetal  movements,  as  a  result  of  which,  or 
of  the  stasis  and  pressure  during  the  first  third  of  fetal 
life  when  the  heart  is  still  pulsating,  we  have  twisting  of 
the  umbilical  cord  (most  marked  at  the  navel,  Figs.  88  and 
100),  or  the  formation  of  coils  about  the  trunk,  neck,  and 
extremities  and  true  knotting  of  the  cord,  all  which  condi- 
tions in  turn  lead  to  interference  with  the  fetal  blood 
circulation. 

A  woman  is  very  liable  to  syphilitic  infection  at  the 
time  of  conception  or  during  pregnancy.  The  more  recent 
the  syphilitic  infection  in  the  father  or  in  both  parents 
(the  father  may  infect  the  fetus  without  infecting  the 
mother),  the  more  likely  is  abortion  to  result.  From  the 
time  of  infection  until  four  weeks  before  birth  premature 
delivery  rarely  takes  })lace  ;  on  the  other  hand,  however, 
infection  of  the  infant  is  common.  If  the  fetus  does  not 
die  in  utero  and  undergo  maceration,  the  symjDtoms  may 
be  very  slight :  malnutrition,  insufficient  increase  in  weight 
from  the  very  beginning,  and  gradual  decline  during  the 
first  year  of  life ;  the  characteristic  pemphigoid  eruption 
on  the  soles  of  the  feet  and  palms  of  the  hands ;  the  len- 
ticular roseola  syphilitica;  the  nodular  form  of  lichen  ; 
rliagades  about  the  various  orifices  of  the  body  ;  ecthyma 
pustules  (containing  pus) ;  dropsy  of  peripheral  portions 
and  of  the  skin  and  often  ascites  and  hydrothorax,  in- 
cluding a  large  number  of  cases  of  hydrocephalus  which 
can  now  with  certainty  be  included  in  this  category ; 
osteochondritis  at  the  boundary  between  the  epiphyses  and 
diaphyses,  especially  of  the  tibia  and  femur;  hepatic 
enlargement  from  overgrowth  of  connective  tissue,  gastric 
ulcers  (forming  a  part  of  the  cases  of  melaena  neonatorum), 
and  interstitial  pneumonia  (asphyxia). 

The  syphilitic  poison  may  pass  through  the  mother  to 
the  placenta  and  thence  to  the  fetus,  but  such  a  mode  of 
transmission  is  rare.  In  the  great  majority  of  cases  the 
infection  of  the  ovum  dates  from  the  coitus  with  the  in- 
fected father ;  probably  it  may  also  be  directly  involved 


152      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  96.  Placental  Infarct  in  Eclampsia,  consisting  in  subamniotic 
necrotic  foci  (original  water-color  drawing  after  the  author's  own  prepa- 
ration from  the  Heidelberg  Gynecological  Clinic  ;  marginal  insertion  of 
the  cord). 

in  maternal  infection,  and,  furthermore,  the  germ  may 
pass  from  the  infected  ovum  to  the  healthy  mother,  bat 
such  a  mode  of  transmission  to  the  mother  is  rare  (choc  en 
retour),  evidently  because  the  fetal  specific  toxins  tend  to 
render  the  mother  immune,  and  she,  therefore,  usually  does 
not,  as  a  rule,  become  "  retro-infected  '^  (Colles's  law). 

Treatment. — Sodium  iodide,  gr.  iiss  to  iv  to  xv  (0.15  to 
0.25  to  1  gm.)  per  day ;  calomel,  gr.  f  to  iss  to  iij  (0.05  to 
0.1  to  0.2  gm.),  three  times  a  day,  occasionally  as  a  laxa- 
tive and  also  for  the  purpose  of  mercurialization ;  Unna's 
mercurial  plaster  mulls  instead  of  inunctions,  and  colloidal 
mercury.  A  syphilitic  infant,  or  an  infant  born  of  syph- 
ilitic parents,  although  apparently  healthy,  must  never  be 
given  to  a  nurse ;  neither  should  a  healthy  mother  nurse 
a  diseased  infant.  The  infant  should  be  bathed  in  subli- 
mate baths  (1  gm.  in  20  quarts  [liters]  of  water)  and 
should  receive  calomel,  gr.  -^-^  to  -I-  (0.005  to  0.0075  gm.), 
and  Dover's  powder,  gr.  2V  to  -^^  (0.003  to  0.005  gm.), 
three  times  a  day.  As  regards  the  physician's  consent  to 
marriage,  it  should  be  given  only  when  five  years  have 
elapsed  from  the  time  of  infection  and  three  years  from 
the  last  manifestation  of  the  disease.  Immediately  before 
marriage  the  patient  should  be  subjected  to  an  inunction 
cure.  The  individual  should  always  be  cautioned  about 
the  danger  of  infection  from  erosions  on  the  genitalia  and 
on  the  mouth. 

I  13.  ECLAMPSIA  GRAVIDARUM. 

Whether  eclampsia  gravidarum  (rarely,  puerperarum) 
is  an  infectious  disease  or  not  is  still  an  open  question. 
That  it  owes  its  origin  to  a  specific  contagium  has  never 
been  proved  and  does  not  appear  probable.  It  is  possible 
that  compression  of  the  ureters  (directly  or  indirectly  as 
a  result  of  stasis  in  the  vascular  or  lymphatic  circulation) 


Tab.  44. 


Fig.  96. 


lf//>  A/i.sf  E  Reichhold.  Mmichen 


ECLAMPSIA   GRAVIDARUM.  153 

by  the  entrance  of  the  chilcVs  head  into  the  true  pelvis  is 
foHowed  by  secondary  interference  with  the  renal  secretion, 
and  that  this  in  turn  leads  to  retention  within  the  blood 
of  various  kinds  of  micro-organisms  and  especially  of 
their  toxins,  or,  in  other  words,  ptomains,  tlie  presence  of 
which  may  produce  toxic  metabolic  products  in  the 
various  organs  of  the  body  (leucomains).  The  explana- 
tion Avhich  appears  to  be  most  probable  is  that  toxins, 
especially  insuiiiciently  oxidized  products  of  metabolism, 
are  retained  as  a  result  of  insufficiency  of  the  liver  and 
kidneys  in  individuals  whose  organisms,  owing  to  their 
neuropathic  habit,  fails  to  adapt  itself  both  in  the  matter 
of  circulation  and  of  internal  metabolism  to  the  chanws 
in  these  functions  incident  to  pregnancy. 

If  the  hepatic  and  renal  insufficiency  and  the  retention 
of  metabolic  toxins  (leucomains)  reach  a  high  degree 
toward  the  end  of  pregnancy,  the  nervous  impulses  at- 
tending the  act  of  respiration  give  rise  to  abnormal 
reflexes  of  the  intoxicated  nervous  system  (clonic  con- 
vulsions) and  to  disturbances  in  the  circulation.  In  this 
way  we  may  explain  the  acetone  and  sugar  found  in  the 
urine  by  Stumpf.  as  well  as  the  amyloid  and  fatty  degen- 
eration of  the  kidneys,  liver,  brain,  etc.,  attended  with 
thrombosis  and  apoplexy  or  with  edema  and  anemia  in 
these  organs.  Thus,  for  instance,  acetonuria  can  be  pro- 
duced experimentally  by  excluding  the  celiac  ganglion  of 
the  sympathetic  nerve. 

There  is  no  doubt  that  pressure  conditions  and  irritative 
processes  in  the  pelvis,  involving  the  sympathetic  ganglion 
and  the  ureters,  play  an  important  and  very  frequent  part 
in  the  etiology.  Hence,  the  first  pregnancy — on  account 
of  the  early  descent  of  the  head — double  and  triple 
pregnancies,  and  generally  contracted  pelves  are  counted 
among  the  predisposing  causes.  Flat  or  anteroposteriorly 
contracted  pelves  do  not  produce  the  condition  because 
the  deeply  excavated  ''  dead  space  '^  (from  an  obstetrical 
point  of  view)  alongside  of  the  projecting  promontory 
protects  the  ureters  and  blood-vessels.     There  is  no  single 


154      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  97.  Uterus  Bicornis  Septus. — Child  in  first  face  presentation : 
chin  posterior,  tlie  contractions  of  the  uterus  having  forced  the  axis  of 
the  child's  body  obliquely  against  the  opposite  walls  of  the  pelvis.  C}C^^, 
the  two  coriuia  of  the  uterus  ;  G.R.,  contraction-ring. 

Fig.  98.  Uterus  Introrsum  Arcuatus. — Oblique  position  la  with 
shoulder  presenting.  The  depression  in  the  fundus  is  very  marked  ;  it 
could  not  be  palpated  in  the  foregoing  case.     Lettering  as  in  Fig.  97. 

Fig.  99.  Pendulous  Abdomen  of  tlie  Third  Degree. — Sagittal  section 
showing  the  position  of  the  child  and  the  vaginal  portion  of  the  cervix. 
The  fundus  of  the  uterus  is  lower  than  the  vaginal  portion  of  the  cervix 
(original  drawing). 


cause,  or,  to  be  more  exact,  there  may  be  a  single  cause, 
but  there  is  no  single  exciting  cause,  to  account  for  the 
outbreak  of  the  symptom-complex  which  is  known  as 
eclampsia.  The  usual  time  of  appearance  is  during  the 
last  three  months  of  pregnancy.  In  isolated  cases  there 
is  no  nephritis. 

The  symptoms  consist  in  attacks  of  clonic  convul- 
sions, beginning  at  the  head  and  extending  downward. 
The  severe  headache  with  debility  and  oppression  observed 
before  the  attack  is  replaced  by  unconsciousness  ;  the  face 
becomes  cyanotic,  the  pulse  small  and  rapid,  respiration 
accelerated,  sighing  or  blowing,  and  accompanied  with 
diaphragmatic  spasm.  The  facial  and  ocular  muscles  are 
also  involved  in  the  convulsions. 

The  attack,  which  lasts  from  one-half  to  one  and  one- 
half  minutes,  is  followed  by  a  condition  of  coma  with  a 
rise  of  temperature  and  acceleration  of  the  lieart-beat. 
The  face  becomes  pale  and  pulmonary  edema  is  very  apt 
to  develop. 

The  urine  always  contains  albumin,  fibrinous  casts 
(also  red  and  white  blood-corpuscles),  sugar,  acetone ;  the 
amount  is  very  much  diminished  and  the  acidity  greatly 
increased.  Experiments  with  the  urine  and  blood  indicate 
that  they  are  extremely  toxic  and  contain  large  masses  of 
leucomains. 

Among  the  prodromal  symptoms  and  consequences  of 
an  attack  may  be  mentioned  headache  with  nausea  and 
vertigo,  amblyopia  and  amaurotic  symptoms,  pneumonia, 


as 


I 


ECLAMPSIA   GRAVIDARUM.  155 

loss  of  memory  for  past  events,  maniacal  conditions 
temporary  in  character  and  preceded  by  fits  of  taciturnity, 
alternating  with  garrulity,  laughter,  etc.  Oliguria  or 
anuria  are  frequent  prodromal  symptoms. 

The  consequence  to  the  fetus  is  death,  either  at  the 
time  of  birth,  which  is  usually  premature,  or  during  preg- 
nancy, without,  in  the  latter  ca^e,  the  death  of  the  fetus 
being  necessarily  followed  by  delivery,  although  the 
attacks  cease  with  the  death  of  the  child.  Sometimes 
children  are  delivered  in  a  condition  of  rigidity,  and,  on 
the  other  hand,  eclampsia  neonatorum  has  been  observed 
without  any  eclamptic  symptoms  on  the  part  of  the  mother, 
who,  however,  suffered  from  nephritis.  Finally,  there 
may  be  changes  in  the  tissues  of  the  placenta  such  as  have 
been  described  above.  After  delivery  the  attacks  usually 
cease,  but  they  may  be  readily  provoked  by  massage  of 
the  uterus  or'  the  expression  of  the  placenta  by  Crede's 
method. 

The  treatment  consists  in  administering  enemata  of 
chloral  hydrate,  gr.  xv  to  xxx  (1  to  2  gm.),  after  every 
attack;  siijtoiv  (12  to  15  gm.)  per  day  (v.  Winckel),  or 
subcutaneous  injections  of  morphine  as  high  as  gr.  ss 
(0.03  gm.)  at  each  attack  (G.  Yeit  has  given  as  high  as 
gr.  iij  [0.2  gm.]  in  four  to  seven  hours) ;  and,  finally,  in 
administering  chloroform,  but  only  for  a  short  time  and 
provided  the  pulse  is  full  and  of  good  tension.  Subcuta- 
neous injections  of  decinormal  salt  solution.  Prolonged 
immersion  in  a  bath  of  from  97°  to  104°  F.  (36.2°  to 
40°  C.)  or  an  equivalent  warm  pack  for  the  purpose  of 
inducing  diaphoresis  is  to  be  recommended.  Delivery  is 
to  be  effected  as  soon  as  possible,  that  is,  as  soon  as  it  can 
be  done  without  danger  to  the  mother,  either  by  dilating 
or  incising  the  os.  The  patient  is  to  be  watched  con- 
stantly, and  a  piece  of  wood  or  a  spoon  or  other  object 
covered  with  cloth  must  be  inserted  into  her  mouth  to 
prevent  injury  to  the  tongue.  Every  unnecessary  disturb- 
ance is  to  be  avoided.  Great  care  must  be  exercised  in 
giving   liquids,    as    inhalation-pneumonia   might    result. 


156  THE  PATHOLOGY  OF  PREGNANCY. 

Prophylaxis  includes  the  treatment  of  the  nephritis,  the 
regulation  of  the  bowels,  the  induction  of  diaphoresis, 
and  a  milk  diet. 

§  14.  THE  RELATIONS    BETWEEN  PREGNANCY  AND 
DISEASES  OF  OTHER  ORGANS. 

As  has  been  mentioned,  general  febrile  infectious  dis- 
eases frequently  lead  to  abortion,  either  by  setting  up  a 
local  endometritis  and  decidual  hemorrhages,  or  by  fa- 
voring the  accumulation  of  heat  and  the  transmission  of 
toxins,  or,  more  rarely,  of  bacteria  themselves.  In  typhoid, 
fever  most  patients  who  recover  abort.  In  variola  they 
recover  without  abortion,  the  children  being  immunized 
in  utero  and  born  with  pockmarks,  but  if  abortion  takes 
place  most  patients  die.  In  cholera  recovery  and  death 
occur  indifferently  with  or  without  abortion. 

Vaccination  of  the  pregnant  mother  does  not,  as  a  rule, 
render  the  child  immune. 

Influenza,  according  to  my  observations,  leads  to  pelvic 
congestion  and  abortion  or,  more  rarely,  to  premature  labor, 
depending  on  the  severity  of  the  epidemic.  Abortion  is 
less  rapid,  but  often  associated  with  more  copious  hemor- 
rhage. The  placenta  is  unusually  soft ;  the  subsequent 
discharges  are  often  fetid.  The  usual  nervous  phenomena 
of  influenza  are  present  and  occasionally  alternate  with 
maniacal  conditions. 

The  occurrence  of  erysipelas  during  pregnancy  is  a  seri- 
ous complication  on  account  of  the  great  danger  of  septic 
infection  during  delivery.  Cases  of  septic  infection  of 
the  mother  during  pregnancy  almost  always  result  in 
death  of  the  fetus.  Streptococci,  staphylococci,  and  the 
bacterium  coli  have  been  found  in  the  blood  of  such  fe- 
tuses. Tetanus  has  been  observed  in  a  few  cases,  usually 
after  an  operation.  The  uterus  does  not  take  part  in  the 
muscular  contractions.  Although  the  poison  passes  through 
the  placenta  and  causes  the  death  of  the  fetus  it  does  not 
produce  abortion  directly. 


PREGNANCY  AND  DISEASES  OF  OTHER  ORGANS.    157 

Scarlatina  runs  the  same  cour.se  as  in  non-pregnant 
women.  There  is  a  pseucloscarlatinal  eruption  which 
manifests  itself  as  a  sf)ecial  form  of  septic  infection  dur- 
ing the  puerperiiim.  In  morbilli  fetuses  have  repeatedly 
been  born  with  the  eruption  of  measles  in  various  stages, 
and  the  eruptive  stage  can  be  recognized  by  the  increase 
in  fetal  movements. 

Impetigo  herpetiformis  gravidarum  is  a  somewhat  rare 
infectious  disease  of  very  grave  prognosis,  for  which 
reason  it  is  important  to  be  able  to  recognize  it.  It 
appears  in  the  form  of  vesicles  and  pustules  in  the  genital 
region  and  later  spreads  to  tlie  abdomen  and  to  the  neck ; 
it  also  attacks  the  mucous  membrane  of  the  intestinal 
tract  and  leads  to  hemorrhages  from  the  bowel.  The 
disease  often  results  in  abortion  and  frequently  in  death. 
Timely  induction  of  premature  labor  is  indicated,  as  the 
disease  usually  does  not  appear  before  the  middle  of 
pregnancy. 

Otherwise  there  is  no  indication  to  induce  artificial 
abortion. 

I  also  agree  with  Fritsch  in  laying  it  down  as  a  maxim 
that  the  induction  of  premature  labor  is  not  indicated  in 
cardiac  disease  (digitalis  and  ether  should  be  employed) 
nor  in  diseases  of  the  lungs. 

Before  deciding  that  the  induction  of  labor,  or,  rather, 
the  termination  of  pregnancy,  is  necessary  and  more  ad- 
vantageous to  the  woman  than  delivery  at  term,  we  must 
have  special  reasons  based  on  the  individual  peculiarity 
and  the  merits  of  each  particular  case.  Such  indications 
are  found  in  the  literature  and  in  the  symptomatology  of 
cardiac  diseases  complicating  pregnancy. 

If  there  is  perfect  compensation  pregnancy  runs  a  favor- 
able course  if  the  woman  lives  a  rational  life.  If  com- 
pensation fails  the  condition  usually  remedies  itself  by  a 
spontaneous  abortion.  If  the  latter  does  not  occur  it  is 
often  possible,  by  bringing  about  compensation  (digitalis 
except  in  aortic  insufficiency,  ether,  or  venesection),  to 
bring  the  pregnancy  to  a  successful  termination.     If  com- 


158      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  100,  Twisting  of  the  Umbilical  Cord  and  Oligohydramnion  of  a 
Dead  Twin. — The  torsion  is  greatest  at  the  navel.  This  fetus  was  re- 
stricted to  a  very  small  nutritive  area  ou  the  placenta.  The  cord  of  the 
other  living  twin  (lodged  in  the  polyhydramniotic  sac)  presents  elon- 
gated arteries  with  circumscribed  accumulations  of  Wharton's  jelly,  so- 
called  "false  knots"  (original  drawing  from  a  preparation  in  the 
Munich  Gynecological  Clinic). 

Fig.  101.  Placental  Infarcts,  wedge-shaped,  penetrating  deep  into  the 
choriodecidual  tissue,  from  a  case  of  eclampsia  (original  drawing  after 
a  preparation  from  the  Munich  Gynecological  Clinic). 


pensation  cannot  be  effected  the  successful  result  of  arti- 
ficial removal  of  the  ovum  will  depend  on  the  prompt- 
ness with  which  the  ovum  is  expelled  and  on  the  duration 
of  the  pregnancy ;  in  other  words,  on  the  amount  of  ex- 
ertion necessary  to  expel  the  ovum  and,  of  course,  on 
the  severity  of  the  disease  itself.  Labor-pains  and  the 
changes  in  blood-pressure  which  they  produce  are  far 
more  dangerous  than  the  alterations  in  the  circulation 
during  pregnancy,  and  we  know  that  a  premature  delivery 
lasts  longer  than  delivery  at  term.  The  best  method  in 
such  cases  consists  in  puncture  of  the  sac,  because  the 
woman  is  immediately  relieved  of  her  burden.  Rational 
indication  for  the  artificial  induction  of  premature  labor 
exists,  therefore,  in  those  cases  in  which  the  cardiac  action 
is  endangered  less  by  the  momentary  shock  of  expulsion 
than  by  the  duration  of  the  circulatory  embarrassment, 
especially  in  aortic  valvular  disease. 

The  mortality  given  by  clinicians,  from  30  to  60  per 
cent,  (average  40  per  cent,  in  two  hundred  and  fifty  cases), 
is  too  high  ;  while,  on  the  other  hand,  the  mortality  of  6  per 
cent.,  which  was  obtained  in  Gusserow's  obstetrical  clinic, 
is  too  low  for  the  conditions  met  with  in  private  practice ; 
from  10  to  15  per  cent,  probably  represents  the  true 
figure,  depending  on  whether  the  woman  has  previously 
been  under  the  care  of  a  physician  or  not,  as  diet  and 
proper  treatment  exert  a  marked  influence  on  the  cardiac 
condition. 

In  the  case  of  hard-working  women  the  prognosis 
should  be  more  guarded  than  in  the  case  of  those  who 


o 
'3 


PREGNANCY  AND  DISEASES  OF  OTHER  ORGANS    159 

are  able  to  spare  themselves  and  live  a  rational  life.  If 
the  lesion  is  acquired  in  early  youth  the  prognosis  is  also 
less  favorable.  It  is  also  affected  by  the  age  of  the 
patient,  the  number  of  previous  pregnancies,  and  the  con- 
sequent using  up  of  cardiac  force.  For  this  reason  the 
condition  of  the  heart-muscle  is  quite  as  important  as  the 
particular  variety  of  valvular  lesion.  Myocarditis  and 
degeneration  of  the  heart-muscle  influence  the  prognosis 
very  unfavorably.  The  induction  of  abortion  is  posi- 
tively indicated  before  the  fourth  month  if  these  condi- 
tions are  present.  In  the  operation  of  inducing  abortion 
it  must  not  be  forgotten  that  the  resisting  power  of  the 
mucous  membranes  is  much  reduced  by  the  existing  local 
disturbance  of  the  circulation  and  that  they  are,  there- 
fore, particularly  liable  to  infection.  Cardiac  shock  and 
postpartum  hemorrhages  are  best  treated  by  the  applica- 
tion of  a  sand-bag  to  the  lower  part  of  the  abdomen 
(perhaps  the  inhalation  of  amyl  nitrite  or,  better,  ether, 
but  ergotin  should  never  be  given).  The  patient's  rela- 
tives should  have  the  desperate  nature  of  the  case  fully 
explained  to  them  beforehand.  Complication  with  renal 
affection  must  not  be  disregarded,  as  the  consequent 
retention  of  toxins  adds  another  burden  to  the  work  of 
the  heart.  The  same  is  true  of  gastric,  intestinal,  and 
he])atic  insufficiency. 

The  physician  may  give  his  consent  to  marriage  except 
in  cases  of  debilitated  and  very  anemic  and  neurasthenic 
individuals,  or  when  the  heart-lesion  has  been  acquired 
early  in  life  and  when  there  is  degeneration  of  the  heart- 
muscle  and  marked  failure  of  compensation,  especially  if 
there  is  reason  to  expect  that  the  woman  will  have  to  lead 
a  hard  life. 

In  lung  diseases  (croupous  pneumonia  and  especially 
phthisis)  the  course  of  the  pregnancy  itself  is  usually 
favorable  ;  on  the  other  hand,  the  act  of  parturition  is 
apt  to  give  rise  to  grave  disturbances  on  account  of  the 
loss  of  blood,  the  muscular  exertion,  and  the  imminent 
danger  of  cardiac  insufficiency  and  consequent  pulmonary 


160      THE  PATHOLOGY  OF  PREGNANCY. 

edema.  The  rule  is  to  be  emphasized  that  premature 
labor  is  not  to  be  induced  artificially,  but  as  soon  as  labor 
has  begun  it  should  be  terminated  as  rapidly  and  with  as 
little  distress  to  the  patient  as  possible. 

The  passage  of  tubercle  bacilfi  through  the  uninjured 
placenta  to  the  fetus,  although  very  difficult,  has  been 
demonstrated  in  a  few  cases,  both  bacteriologically  and 
clinically. 

Finally,  it  should  be  mentioned  that  there  are  cases 
of  hemoptysis  during  pregnancy  which  have  nothing  to 
do  either  with  tuberculosis  or  with  nephritis. 

There  is  a  group  of  diseases  which  present  the  most 
intimate  relation  with  pregnancy  :  they  are  the  disturb- 
ances of  metabolism  and  nervous  diseases. 

Their  symptoms  depend  on  toxic  effects,  due  either  to 
the  formation  of  abnormal  metabolic  products  or  to  the 
retention  of  such  products ;  in  other  w^ords,  on  auto- 
intoxication in  its  widest  sense.  In  chronic  metallic  in- 
toxications, such  as  lead-poisoning,  abortion  is  frequent ; 
the  woman  should  not  be  allowed  to  nurse  her  child,  as 
the  milk  contains  lead. 

The  theory  that  hysteroneurasthenic  conditions  and  functional 
neuroses  following  an  auto-intoxication  are  due  to  imperfect  oxi- 
dation in  internal  metabolism  is  constantly  gaining  ground,  and 
finds  more  and  more  support  in  the  results  of  experimental  and 
pathological  chemical  investigations.  It  is  well  known  that  an 
albuminuria  may  follow  violent  exertion,  that  the  blood  as  well 
as  the  urine  of  neurasthenic  patients  contains  metabolic  prod- 
ucts, both  qualitatively  and  quantitatively  abnormal  (uric  acid, 
phosphates,  albumin,  \irobilin,  leucin,  xanthin,  hypoxanthin, 
indican,  levulose,  etc.),  and  that  in  the  pregnant  organism  certain 
substances  are  formed  and  can  be  demonstrated  in  the  urine, 
which  are  capable  of  producing  convulsions  and  may  lead  to 
albuminuria  and  the  typical  picture  of  the  "kidney  of  preg- 
nancy." It  is  true,  moreover,  that  as  a  result  of  this  relative  or 
absolute  auto-intoxication  the  reflex  irritability  in  the  central 
nervous  system  is  greatly  increased,  owing  to  the  anemia  which 
results  from  the  congestion  in  the  abdominal  walls  (vomiting  of 
pregnancy),  and  that  in  neuropathic  pregnant  women  the  already 
existing  anomalies  of  the  internal  metabolism,  including  those 
of  the  thyroid  gland,  become  accentuated  and  easily  lead  to  renal 


PREGNANCY  AND  DISEASES  OF  OTHER  ORGANS.    161 

and  hepatic  insufficiency.  The  reflexes  are,  therefore,  markedly 
increased,  especially  if  the  woman  is  the  subject  of  a  reflex  neu- 
rosis (hyperemesis  gravidarum,  ptyalism,  tussis  uterina,  diarrhea 
gravidarum,  eclampsia,  icterus  gravidarum). 

In  various  intoxications  due  to  metals,  bacterial  toxins, 
and  toxic  metabolic  products,  including  peptotoxins  of 
gastric  origin  with  pernicious  anemia,  the  nutrition  of  the 
motor  cells  in  the  anterior  horns  is  usually  found  to  be 
affected  earlier  than  that  of  the  posterior  columns,  the  in- 
verse order  being  very  rare. 

Examination  of  the  urine  of  eclamptic  patients  re- 
veals large  quantities  of  leucomains.  We  also  find  in 
the  urine  of  women  suffering  from  hyperemesis  the  fol- 
lowing substances :  large  quantities  of  urobilin,  which 
may  be  derived  either  from  hemoglobin  or  from  bilirubin, 
that  is  to  say,  either  from  the  decomposition  of  blood  or 
from  hepatic  disease ;  acetone ;  peptone  usually  ;  in- 
creased amount  of  oxalic  acid ;  skatoxyl  ;  indoxyl ;  a 
large  amount  of  urinary  sediment ;  hyaline  and  granular 
casts  frequently  ;  occasionally  blood-corpuscles,  fatty 
epithelium,  triple  phosphates,  sodium  urates,  and  oxalates 
of  calcium.  These  findings  show  a  marked  resemblance 
to  the  condition  of  the  urine  found  in  infectious  dis- 
eases, or,  in  other  words,  in  intoxications  by  toxins  formed 
within  the  body. 

Hyperemesis  is  to  be  regarded  as  an  exaggerated  reflex 
neurosis  due  to  an  auto-intoxication,  based  on  a  general 
neuropathic  habit  or  in  some  cases  undoubtedly  on  simple 
hysteria.  For  practical  purposes  it  is  important  to  dis- 
tinguish three  stages  :  the  patient  may  vomit  immediately 
after  taking  food  and  be  able  to  retain  a  little ;  the 
patient  may  vomit  from  an  empty  stomach  and  suffer 
from  constant  nausea,  so  that  she  can  take  very  small 
amounts  not  only  of  solid  but  also  of  liquid  food ;  and, 
finally,  the  patient  may  suffer  from  constant  retching, 
going  on  to  hematemesis,  with  insomnia  and  fever,  and 
become  very  much  debilitated ;  attacks  of  syncope, 
icterus,  and  death  may  follow, 
n 


162  THE  PATHOLOGY  OF  PREGNANCY. 

The  treatment  is  based  on  the  etioh)gy.  It  should 
be  directed  chiefly  toward  overcoming  the  hysteroneu- 
rasthenic  abulia  (loss  of  will  power)  ;  the  ingestion  of 
food  or  medicaments  by  the  mouth  should  be  abandoned  ; 
enemata  of  decinormal  salt  solutions  and  diaphoretic 
remedies  should  be  given  to  stimulate  elimination  of 
toxins  through  the  skin  (wet  packs)  ;  and^  finally,  if  even 
the  administration  of  an  enema  provokes  the  vomiting 
reflex,  hypodermic  injection  of  salt  solution  is  indicated. 
As  the  patient  improves  she  should  be  made  to  take  large 
quantities  of  milk  and  then  be  put  on  a  gradually  in- 
creasing strengthening  diet,  the  bowels  being  regulated 
by  means  of  enemata  and  hydrotherapy.  Treatment  in 
an  institution  under  strict  control  will  prove  most  effica- 
cious of  all.  The  question  of  inducing  abortion  rarely 
needs  to  be  considered,  but  if  it  is  to  be  done  at  all  it 
should  not  be  put  off  too  long,  as  cases  have  been  re- 
ported in  which  tlie  patient  succumbed,  after  spontaneous 
or  artificial  abortion,  to  the  complete  insufficiency  of  all 
the  organs. 

In  a  number  of  cases  the  primary  cause  is  to  be  found 
in  anomalies  of  the  genital  organs  in  connection  with  the 
same  neurotic  diathesis.  Retroflexion  of  an  incarcerated 
uterus  ;  spastic  conditions  of  the  retro-  or  anteflected 
uterus  wnth  descent  of  the  body  ;  hydramnion  ;  hydatid 
mole  ;  decomposition  of  a  hematoma  retained  in  utero, 
twin  pregnancy.  According  to  the  condition  present, 
relief  is  obtained  by  the  induction  of  abortion,  punc- 
ture of  the  amniotic  sac,  freeing  the  pole  of  the  ovum 
by  dilating  the  cervix  without  necessarily  bringing  on 
abortion  (Copeman's  procedure).  Occasionally  manipu- 
lations of  this  kind  act  by  suggestion  in  hysterical  women. 
Mild  grades  of  hyperemesis,  especially  such  as  depend  on 
a  true  local  dyspeptic  trouble,  are  successfidly  treated 
with  basic  orexine  (Frommell),  gr.  v  to  viij  (0.3  to  0.5 
gm.),  in  capsules,  two  or  three  times  a  day. 

Ptyalism  also  occasionally  occurs  and  runs  a  course  with  similar 
alarming  symptoms.     Diaphoresis  and  diuresis  should  be  stimu- 


PREGNANCY  AND  DISEASES  OF  OTHER  ORGANS.    163 

lated  by  hydrotherapeiitic  measures  (junii)er  berry,  if  there  is  no 
nephritis)  and  the  bowels  moved  reguhirly.  In  regard  to  drugs, 
I  have  seen  good  results  follow  the  administration  of  atropine  or 
of  agaricin,  unless,  as  is  often  the  case,  hyperemesis  exists;  potas- 
sium bromide  is  of  no  value.  I  once  used  agaricin  in  a  case  in 
which  ptyalism,  protracted  attacks  of  violent  hyperidrosis,  diar- 
rhea, and  rellex  vomiting  alternated  at  various  times  and  at  various 
pregnancies  in  the  same  woman.  I  have  noticed  this  variety  of 
nervous  diarrhea  in  pregnant  women  whose  urine  contains  large 
quantities  of  uric  acid  at  various  times  and  who  inherit  the  neu- 
ropathic and  gouty  diathesis.  Temporary  relief  was  obtained  in 
such  cases  by  bismuth  and  opium  powder,  tincture  of  thebaine, 
proper  dieting,  and  diaphoretic  measures. 

Tiissis  uterina  is  undoubtedly  a  reflex  neurosis  in  many  cases  and 
is,  therefore,  to  be  treated  both  locally  and  constitutionally  with 
tonics  and  sedatives.     Narcotics  must,  however,  be  avoided. 

Icterus  gravidarum  is  usually  a  symptom  of  hepatic  insufficiency 
associated  with  hyperemesis,  and  occasionally  goes  on  to  an  acute 
yellow  atrophy,  which  is  not  due  to  infection,  but  to  intoxication, 
and  may  give  rise  to  attacks  of  eclampsia.  In  a  few  cases  it  leads 
to  habitual  abortion. 

Diabetic  symptoms,  including  pruritus  vulvse,  are  ag- 
gravated by  pregnancy  in  three-fourths  of  all  the  cases. 
The  fetus  is  born  under  weight  and  greatly  debilitated  or 
dies  in  the  second  half  of  pregnancy  Avith  or  without 
polyhydramnion.  The  presence  of  slight  glycosuria 
toward  the  end  of  pregnancy  is  physiological.  The  in- 
duction of  abortion  depends  on  the  possibility  of  checking 
the  sugar  excretion  and  the  rapid  deterioration  of  the 
entire  organism.  Otherwise  the  usual  regime  is  to  be 
instituted,  which,  indeed,  according  to  Kleinwachter's 
extensive  studies,  is  to  be  preferred  in  the  great  majority 
of  cases.     Diabetic  p-irls  should  not  marrv. 

The  prognosis  in  79r/?»(7?'y  grave  anemia  of  pregiiaiicyh  very  bad  ; 
most  of  the  authorities  are  against  the  induction  of  abortion. 
Some  cases  are  reported,  however,  which  have  been  cured  in  this 
way.  In  leukemia  induction  of  abortion  or  premature  labor  is 
indicated. 

Hemophilia,  purpura  hremorrhagica,  and  scorbutus  are  very  apt  to 
cause  abortion  on  account  of  the  hemorrhages  ;  abortion  should 
never  be  induced  artificially. 

Basedow's  disease  is  unfavorably  influenced  by  pregnancy  and 
not  rarely  leads  to  abortion. 


164  THE  PATHOLOGY  OF  PREGNANCY. 

Many  forms  of  netiritis  with  hyperemesis  which  occur  during 
pregnancy  are  evidently  to  be  regarded  as  due  to  toxins  acting 
especially  on  the  corresponding  portions  of  the  spinal  cord  ;  thus 
we  have  in  many  cases  symptoms  of  bulbar  disease. 

Hysteria  is  not  influenced  by  pregnancy.  Epileptic  women 
appear  to  be  improved  in  one-half  of  all  the  cases.  Psychoses 
appearing  in  the  first  months  of  pregnancy  usually  disappear 
after  the  fourth  month,  although,  strange  to  say,  they  not  rarely 
reappear  during  the  puerperium  ;  the  prognosis  depends  on  he- 
redity and  not  on  the  fact  that  the  woman  is  pregnant.  Melan- 
cholia is  the  most  frequent  manifestation.  Maniacal  symptoms 
may  occasionally  appear,  but  only  secondarily.  Tetany  has  been 
observed  a  few  times  during  pregnancy  after  total  or  partial  ex- 
tirpation of  the  thyroid  gland ;  in  some  cases  it  appears  simulta- 
neously with  uterine  contractions. 

In  chorea  the  prognosis  is  very  grave,  the  mortality  is  30  per 
cent.,  and  premature  labor  occurs  in  20  per  cent,  of  all  cases. 
Induction  of  abortion  is  indicated  if  the  case  is  grave,  the  prin- 
cipal indication  being  insomnia.  Chronic  or  acute  diseases  of  the 
spinal  cord,  such  as  transverse  myelitis,  do  not  interfere  with  nor- 
mal pregnancy  and  parturition,  although  there  may  be  complete 
anesthesia. 

Among  renal  diseases  we  distinguish,  for  practical  pur- 
poses, the  kidney  of  pregnancy,  chronic  nephritis,  and  pur- 
ulent pyelonephritis.  I  have  seen  the  latter  twice  after 
influenza  in  the  fifth  and  seventh  months  respectively,  and 
in  spite  of  the  gravity  and  long  duration  of  the  symptoms 
the  cases  ended  in  successful  delivery,  so  that  I  was  very 
glad  that  I  ^had  not  advised  my  colleague  who  was  in 
charge  of  the  case  to  induce  premature  labor.  The 
proper  treatment  is  diaphoresis  and,  if  necessary,  nephrot- 
omy. In  very  rare  cases  purulent  pyelonephritis  indi- 
cates an  exacerbation  of  renal  tuberculosis.  Pregnancy 
and  floating  kidney  do  not  appear  to  exert  an  unfavorable 
influence  on  each  other  unless  hydronephrosis  co-exists. 

The  term  kidney  of  pregnancy  is  applied  to  certain 
changes  of  an  originally  healthy  kidney  due  to  mechanical 
influences,  or  to  circulatory  alterations,  or  to  the  influence 
of  toxins.  Albuminuria,  gradually  increasing  oliguria, 
the  appearance  of  large  masses  of  fatty  morphological 
elements,  without  red  corpuscles  but  with  a  few  leuko- 
cytes, and  edema  are  the  principal  signs. 


PREGNANCY  AND  DISEASES  OF  OTHER  ORGANS.    165 

The  prognosis  is  good  unless  eclampsia  supervenes.  In 
pregnant  women  who  have  undergone  nephrectomy  the 
prognosis  is  good  so  far  as  we  know  (Fritsch).  The  case 
is  different  with  chronic  nephritis.  The  morbid  process 
increases  in  severity  and  there  is  great  danger  of  retinitis 
albuminurica  or  of  amaurosis  without  ophthalmoscopic 
lesions  and  with  impaired  pupillary  reaction,  and,  occa- 
sionally, of  amblyopia  developing.  The  condition  also  leads 
to  marked  dropsy  and  to  hemorrhages  in  various  mucous 
membranes  and  even  into  the  placenta.  As  a  result  of 
the  latter  the  placenta  may  be  detached  either  suddenly  or 
gradually  by  sclerosis  of  the  vessels  and  the  formation  of 
the  placentar  infarct  (Fehling,  cf.  Figs.  95  and  96),  lead- 
ing to  death  of  the  fetus,  which  is  frequently  dropsical. 

Treatment  must  be  early  and  energetic  and  directed 
to  the  cure  of  the  renal  condition  :  milk  diet,  hypodermic 
injections  of  physiological  salt  solution,  and  diaphoresis 
(during  eclampsia).  If  alarming  symptoms  develop  and 
the  patient's  life  is  threatened,  as  In-  intense  dropsy  or 
retinitis,  with  vision  less  than  one-sixth,  premature  labor 
must  be  induced  with  all  proper  precautions,  so  as,  if  pos- 
sible, to  deliver  a  viable  child.  In  rare  cases  repeated 
attacks  of  hematuria  of  angioneurotic  origin  have  been 
observed  in  simple  hyperemia  of  the  kidneys  in  Avhich 
the  prognosis  was  favorable.  Intestinal  hemorrhages 
have  also  been  reported. 

Traumatism  during  pregnancy  may  be  divided  into  : 
(c?)  Accidental  external  injuries  affecting  the  organs  of 
gestation ;  (h)  Operations,  including  as  a  special  group 
operations  on  the  organs  of  gestation  themselves ;  (c) 
Criminal  abortion  performed  without  the  necessary  pre- 
cautions and  leading  to  coarse  lesions  of  the  organism ; 
(d)  Perforating  peritonitis  and  rupture  of  the  uterus  or 
of  an  ectopic  gestation-sac  during,  or  subsequent  to, 
pregnancy. 

Group  (a),  or  external  injuries  during  pregnancy,  includes  (]) 
certain  special  accidents,  such  as  laceration  of  the  abdomen  and 
gravid  uterus  by  an  angry  cow  or  by  the  knife  of  the  criminal ; 


166      THE  PATHOLOGY  OF  PREGNANCY. 

in  other  words,  a  kind  of  Cesarean  section  has  been  frequently 
reported  in  the  literature,  and,  in  spite  of  the  terrible  mutilation, 
the  accident  did  not  by  any  means  always  result  in  death.  The 
first  Cesarean  section  in  Germany  was  performed  during  the  Mid- 
dle Ages  by  a  swineherd  on  his  own  wife,  and,  although  his  tech- 
nique was  most  primitive,  the  result  was  favorable.  Certain 
tribes  of  negroes  perform  the  operation  with  an  approach  to 
antiseptic  measures,  such  as  the  use  of  red-hot  stone  knives, 
washing  the  wound  with  the  juice  of  some  plant,  and  fumigation. 

(2)  Gunshot  wounds  of  the  abdomen,  either  penetrating  the 
amniotic  sac  and  the  fetus,  or  those  in  which  the  bullet  becomes 
arrested  in  the  uterine  wall  and  does  not  injure  the  ovum.  The 
prognosis  and  treatment  depend  largely  on  whether  or  not  the 
ovum  has  been  injured,  as  I  note  by  a  careful  examination  of  the 
cases  collected  by  Neugebauer.  In  penetrating  wounds  the  amni- 
otic fluid  is  discharged  into  the  peritoneal  cavity  and  the  omentum 
is  swept  into  the  wound,  hence,  infection  being  almost  certain  to 
occur,  immediate  laj)arotomy  is  indicated,  as  it  is  when  the  intes- 
tines are  injured.  After  the  uterus  has  been  evacuated  the  lips 
of  the  uterine  wound  should  be  resected  and  sutured  and  a  Miku- 
licz tampon  inserted  into  the  lower  angle  of  the  wound,  so  that, 
if  necessary,  a  secondary  supravaginal  amputation  can  be  per- 
formed in  case  the  uterus  becomes  infected.  After  non-perforating 
wounds  premature  delivery  usually  occurs  within  a  few  weeks, 
although  the  fetus  is  generally  alive.  In  such  cases  expectant 
treatment  is  indicated  unless  peritoneal  symptoms  develop. 

External  violence  with  a  blunt  instrument,  such  as  a  kick,  a  fall, 
or  a  blow,  while  it  rarely  leads  to  rupture  of  the  uterus,  is  often 
followed  by  separation  of  the  placenta  with  danger  of  death  from 
internal  hemorrhage,  or  the  formation  of  a  hematoma  in  the 
umbilical  cord  or  fetal  membranes  by  the  rupture  of  large  vessels 
in  the  placenta  and  in  the  cord.  A  common  accident  consists  in 
falling  astride  of  the  arm  of  a  chair  or  other  object,  leading  to 
rupture  of  the  engorged  corpora  cavernosa  in  the  region  of  the 
clitoris  and  threatening  the  woman's  life  by  hemorrhage.  There 
is  a  specimen  in  the  Munich  Gynecological  Clinic  of  a  gravid 
uterus  with  twins  which  was  taken  from  a  woman  who  died  of 
hemorrhage  in  this  way  a  quarter  of  an  hour  after  the  accident. 
Other  similar  cases  are  found  in  the  literature.  Compression  and 
ligation  are  the  proper  measures. 

Group  {b).  Urgent  operations  are  to  be  unhesitatingly  performed 
during  pregnancy.  If  the  anesthesia  is  not  protracted  too  long 
there  is  no  danger  to  the  fetus.  It  is  always  proper  to  perform  an 
operation  for  the  removal  of  tumors  or  other  obstacles  which 
would  constitute  absolute  dystocia  at  the  time  of  delivery.  Car- 
cinomata  are  always  to  be  operated  upon  at  once.  Abortion  is 
apt  to  be  induced  only  by  operations  directly  affecting  the  uterine 


PEEGNANCY  AND  DISEASES  OF  OTHER  ORGANS.    167 

wall,  such  as  the  enucleation  of  a  subserous  intramural  myofi- 
broma, or  puncture  through  the  abdominal  walls  for  the  evacuation 
of  hydramnion,  and  operations  on  the  intermediate  and  supra- 
vaginal portion  of  the  cervix.  Ovariotomy  does  not,  as  a  rule, 
brfng  on  abortion.  The  removal  of  adnexa  or  subserous  polypoid 
myoniata  on  one  side  is  usually  well  borne.  The  same  is  true  of 
plastic  operations  on  the  vagina.  Even  the  operation  for  appen- 
dicitis is  not  contra-indicated  by  pregnancy.  As  perityphlitis  not 
rarely  leads  to  abortion  or  premature  labor,  this  condition  occupies 
a  prominent  place  in  the  pathology  of  pregnancy  and  of  the 
puerperium. 

Nephrorrhaphy  for  the  relief  of  a  twisted  kidney  and  local  peri- 
tonitis, nephrectomii  on  account  of  suspected  renal  tumors,  and 
extirpaiioa  of  the  spleen  for  traumatic  rupture  have  been  successfully 
performed.  The  abdominal  scar  becomes  markedly  pigmented 
during  pregnancy,  the  pigmentation  following  the  line  of  the  scar 
and  of  the  sutures  (Fig.  160). 

Group  (c).  Criminal  abortion  usually  consists  in  the  introduction 
of  a  sharp  instrument  for  the  purpose  of  rupturing  the  amniotic 
sac  or  bringing  on  labor-pains.  If  the  instrument  enters  the 
posterior  vaginal  vault  by  mistake,  or  fails  to  follow  the  proper 
curve  after  entering  the  internal  os,  the  peritoneal  cavity  is  per- 
forated. If  aseptic  precautions  are  neglected,  septic  infection 
develops  and  ends  either  in  death  or  in  lifelong  invalidism. 

Group  (c/).  Perforation  Peritonitis. — This  is  caused  in  most  cases 
by  necrotic  pyosalpinx,  or  the  rupture  of  a  peritoneal  abscess,  or 
of  a  gangrenous  bladder  in  retroflexion  of  an  incarcerated  gravid 
uterus  during  the  fourth  month  of  pregnancy.  Death  results 
unless  laparotomy  is  immediately  performed  and  iodoform  gauze 
introduced  into  the  lower  angle  of  the  w^ound  for  the  purpose  of 
drainage  (see  |  13). 

Rupture  of  the  uterus  with  discharge  of  the  ovum  into  the  peri- 
toneal cavity  was  a  fairly  common  accident  in  the  days  before 
antisepsis,  wdien  the  uterine  wound  w^as  not  sutured  after  Cesarean 
section ;  the  accident  usually  ended  in  death.  Now  that  the 
wound  is  carefully  closed  with  a  double  row  of  silk  sutures  (if 
catgut  is  used,  diminution  in  the  thickness  of  the  uterine  wall 
sometimes  occurs  at  the  next  pregnancy)  the  accident  is  rare.  It 
also  occurs  in  ectopic  gestation  in  rudimentary  cornua  (see  |  20  « ; 
15,  1). 

Rupture  of  a  tubal  sac  in  ectopic  gestation  calls  for  removal  of 
the  ovum  and  blood-clots,  either  through  the  vagina  or  through 
the  abdominal  w^all,  on  account  of  the  profuse  intraperitoneal 
hemorrhage  and  the  danger  of  secondary  peritonitis  (see  I  17). 

A  special  group  includes  anomalies  in  the  shape  and 
position  of  the  pelvic  organs,  especially  of  the  genitalia, 


168  THE  PATHOLOGY  OF  PREGNANCY. 

which  may  lead  to  abortion  on  account  of  the  want  of 
room  or  the  primary  and  secondary  disturbances  of  the 
circulation.  But  as  abortion  under  such  conditions  is  a 
comparatively  rare  occurrence  we  shall  reserve  its  discus- 
sion for  the  chapter  on  disturbances  of  pregnancy  in 
general,  which  result  from  those  conditions. 

I  15.  DISTURBANCES  DURING  PREGNANCY  DUE  TO 
ANOMALIES  IN  THE  SHAPE  AND  POSITION  OF  THE 
GENITAL  ORGANS,  ESPECIALLY  THE  UTERUS. 

1.  Malformations  of  the  Uterus. —  Uterus  unicornis  is 
due  to  the  arrest  of  development  of  one  of  Miiller's 
ducts,  as  a  result  of  which  the  uterus  is  imperfectly  de- 
veloped ;  the  organ  usually  occupies  an  oblique  position 
and  is  conical  at  the  fundus.  The  marked  attenuation 
of  the  walls  often  leads  to  rupture  even  during  pregnancy. 
The  diagnosis  cannot  be  made  with  any  certainty,  even 
when  there  is  another  rudimentary,  secondary  horn,  unless 
the  presence  of  a  septum  in  the  vagina  should  arouse  a 
suspicion  of  double  uterus.  There  may  be  impregnation 
of  the  rudimentary  horn  which  cannot  be  distinguished 
from  extra-uterine  pregnancy  and  gives  rise  to  the  same 
dangers,  namely,  rupture  of  the  gestation-sac  as  early  as 
the  middle  of  pregnancy. 

Uterus  bicornis  is  due  to  independent  development  and 
imperfect  union  of  the  two  ducts.  The  wider  the  sepa- 
ration between  the  ducts  the  more  independent  the  func- 
tions of  the  two  portions.  Thus  we  observe  separate 
labor-pains  in  uterus  bicornis,  and  if  both  horns  are 
gravid  there  may  be  a  considerable  interval  between  the 
births  of  the  two  fetuses. 

The  diagnosis  of  uterus  bicornis  is  exceedingly  difficult, 
as  there  is  only  one  portio  vaginalis. 

Uterus  didelphys  (duplex),  or  the  development  of  two 
entirely  independent  uteri  with  complete  separation  of  the 
portio  vaginalis  and  either  a  single  or  a  double  vagina, 
one  of  which  may  be  imperforate.  Even  in  iderus 
septus  (bilocularis)  regular  menstruation  and  ovulation  of 


DISTURBANCES  DURING  PREGNANCY.  169 

one  uterus  may  continue  while  the  other  is  impreg- 
nated. Not  rarely  pregnancy  alternates  in  the  two  uteri. 
Double  pregnancy  has  also  been  observed;  it  gives  rise 
to  marked  disturbances.  At  every  parturition  a  decidua  is 
expelled  from  the  non-gravid  side.  The  diagnosis  is 
somewhat  easier  in  the  slighter,  than  in  the  more  pro- 
nounced, anomalies,  because  in  the  former  the  entire  com- 
mon portion  is  occupied  by  the  ovum  and,  therefore,  the 
two  horns  can  be  recognized  above  it  (Fig.  98),  whereas 
in  pronounced  forms  of  the  malformation  the  ovum  is 
lodged  in  one  side,  the  other  side  undergoing  very  little 
hypertrophy  and  being,  therefore,  difficult  to  palpate 
(Fig.  97).  In  this  anomaly  we  occasionally  meet  with 
premature  delivery  and  rarely  with  rupture  of  the  single 
gravid  horn  during  the  second  half  of  pregnancy,  with- 
out the  occurrence  of  labor-pains  (case  bv  Weil  of 
Teplitz). 

Toward  the  end  of  pregnancy  the  empty  cornu  may, 
if  it  is  lodged  in  the  pouch  of  Douglas,  obstruct  the 
superior  strait  like  a  tumor. 

In  abortions,  especially  if  complicated  with  sepsis,  the 
possibility  of  a  double  uterus  and  vagina  must  always  be 
borne  in  mind. 

Treatment. — In  most  cases  the  pregnancy  runs  a  favor- 
able course ;  but  as  a  number  of  cases  have  been  re- 
ported in  which  rupture  occurred  and  was  almost  imme- 
diately followed  by  death,  it  is  important,  after  such  a 
malformation  has  been  recognized,  to  determine,  if  pos- 
sible, wdiether  the  position,  fixation,  and  thickness  of  the 
Avails  of  the  gravid  portion  are  such  as  to  enable  it  to 
bring  the  ovum  to  maturity.  A  large  number  of  careful 
observations  from  the  very  beginning  of  pregnancy  are 
urgently  needed  to  enable  us  to  determine  the  expediency 
of  inducing  abortion  in  a  concrete  case.  In  any  case 
pregnancy  in  a  rudimentary  horn  is  to  be  treated  on  the 
same  principles  as  an  extra-uterine  pregnancy.  If  the 
abdomen  is  very  much  distended  and  tender  to  the  touch, 
either  of  the  palpating  hand  or  of  the  fetal  parts,  if  there 


170  THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  102.  Retroflexion  of  a  Gravid  Uterus. — Owing  to  severe  ischuria 
and  decomposition  of  the  stagnating  urine  the  entire  vesical  mucosa  has 
undergone  necrosis  and  separated  from  the  wall  of  the  bladder  in  the 
form  of  a  complete  sac  (modified  after  Schatz). 

Fig.  103.  Partial  Retroflexion  of  a  Gravid  Uterus,  secondary  to  total 
incarceration. 

are  great  emaciation  and  insomnia,  even  without  elevation 
of  temperature,  laparotomy  is  indicated.  After  septic 
abortion  of  one  horn  in  double  pregnancy  the  other  horn 
is  to  be  immediately  evacuated. 

2.  Displacements  of  the  Uterus. — Abortion  is  only  rela- 
tively frequent  in  incarceration  of  the  retroflexed  gravid 
uterus.  It  constitutes  a  grave  complication  and  is  for- 
tunately rare  in  comparison  Avith  the  frequency  of  retro- 
version and  retroflexion.  The  displacement  is  unfavor- 
able to  conception  and  favors  abortion  both  mechanically, 
on  account  of  the  position  of  the  uterus,  and  by  the  cir- 
culatory disturbances  to  which  it  gives  rise. 

Retroversion  of  the  gravid  uterus,  that  is,  dislocation 
of  the  fundus  backward  over  the  transverse  axis  of  the 
pelvis  with  the  vaginal  portion  in  front,  without  flexion 
of  the  body  upon  the  cervix,  may  become  converted  into 
retroflexion  if  the  impregnated  body  of  the  uterus  during 
its  growth  descends  in  toto  and  becomes  arrested  under 
the  promontory.  If  the  fundus  is  under  the  promontory, 
but  higher  than  the  external  os,  we  speak  of  the  displace- 
ment as  a  retroflexion  of  the  first  degree;  if  the  fundus  is 
at  the  level  of  the  portio  vaginalis,  it  is  a  retroflexion  of 
the  second  degree;  if  still  lower,  it  is  a  retroflexion  of  the 
third  degree.  The  uterus  may  be  entirely  inverted. 
Toward  the  end  of  the  third  month  the  uterus  either 
pushes  its  way  past  the  promontory,  or  retroflexion  w^ith 
incarceration  is  produced,  which  in  rare  cases  may  con- 
tinue to  the  end  of  a  normal  pregnancy.  If  a  part  of 
the  fetus  escapes  past  the  promontory  we  have  a  partial 
retroflexion  of  the  uterus  (Fig.  103).  Even  then  spon- 
taneous reposition  may  take  place  during  pregnancy  by 
the  upper  portion  descending  forward  and  with  the  assist- 


DISTURBANCES  DURING  PREGNANCY.  171 

ance  of  labor-pains  exerting  traction  on  the  posterior 
lower  portion.  By  the  term  spurious  partial  retroflexion 
we  mean  an  anteflexion  of  the  uterus  in  which  there  is  a 
sacculation  of  the  posterior  wall  from  any  cause  (uterus 
bicornis  with  pregnancy  in  the  posterior  horn,  perime- 
tritic adhesions,  myoma — Diihrssen). 

The  fetal  part  originally  situated  in  the  hollow  of  the 
sacrum — usually  the  head — may,  instead  of  rising,  force 
its  way  downward  and  eventually  cause  bulging  of  the 
perineum  (Fig.  105)  or  of  the  wall  of  the  rectum  ;  or, 
after  perforating  the  posterior  vaginal  wall,  may  cause 
prolapse  of  the  retroflexed  gravid  uterus  (Fig.  109)  and 
appear  at  the  vulva.  The  consequences  of  this  accident, 
aside  from  spontaneous  reduction  with  or  without  abor- 
tion, are  hyperemesis,  ptyalism,  cystitis  with  abortion 
(retention  and  decomposition  of  the  urine  with  necrosis 
and  separation  of  the  vesical  mucosa.  Fig.  102),  halving 
of  the  bladder  in  such  a  way  that  one  part  is  in  front  and 
the  other  behind  and  upon  the  uterus,  and,  finally,  per- 
foration of  the  rectum  and  vagina,  or  usually  fatal  rupture 
of  the  bladder  and  uremia ;  occasionally  death  of  the 
fetus. 

Paradoxical  ischuria  with  absence  of  the  menses  is 
always  an  important  factor  in  the  diagnosis.  Examina- 
tion of  the  size  and  position  of  the  uterus  must  never  be 
neglected.  The  diagnosis  can  be  definitely  established  by 
finding  the  angle  between  the  portio  vaginalis  and  the 
posterior  part  of  the  tumor  continuous  with  it.  The 
tumor  gives  rise  to  a  spherical  bulging  of  the  posterior 
vaginal  vault.  The  condition  must  be  differentiated  from 
tubal  pregnancy  with  chronic  adliesive  peritonitis  and  co- 
existent retroflexion  of  the  uterus,  and  from  retro-uterine 
hematocele. 

I  once  met  with  a  case  of  the  first  kind  which  I  was 
unable  to  diagnosticate  in  the  second,  or  even  in  the  third 
month  until  after  the  reposition  of  the  somewhat  enlarged 
and  softened  uterus,  when  I  was  able  to  demonstrate  by 
palpation  the  growing  tubal  tumqr.     In  such  cases  reposi- 


172  THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  104.  Von  Wiuckel-Eisenhart's  case  of  Hernia  Labialls  Uteri 
Gravidi  Bicornis  :   (7^  C^,  cornua  uteri ;  8,  septum. 

Fig.  105.  Stage  of  Transition  to  Prolapse  of  the  Retroflexed  Gravid 
Uterus,  with  perforatiou  through  the  rectum  or  vagina  or  through  the 
perineum. 

tion  should  not  be  attempted  even  after  the  state  of 
affairs  is  accurately  known,  on  account  of  the  danger  of 
immediate  rupture  of  the  sac. 

Etiology. — Predisposing  factors  are  firm  adhesions,  flat 
pelves  with  projecting  promontories,  tumors,  a  primary 
relaxed  condition  of  the  uterine  walls,  which  become 
thickened  by  chronic  metritis  when  these  conditions  are 
complicated  with  constant  retroversion  of  a  deeply  placed 
uterus. 

The  first  indication  in  the  treatment  is  reposition, 
after  evacuation  of  the  bladder  and  rectum.  Reposition 
is  effected  by  drawing  down  the  cervix  with  Muzeux 
forceps  and  pushing  up  the  body  of  the  uterus,  either 
through  the  posterior  vault  or,  in  a  standing  or  in  Sanger's 
position  (elevation  of  the  pelvis),  through  the  rectum  or, 
possibly,  through  the  abdominal  wall.  In  many  cases 
reposition  requires  the  introduction  of  the  round  elastic 
Mayer's  ring-pessary  or  of  the  colpeurynter  (A.  Miiller), 
that  is,  a  rubber  bladder  which  is  inflated  after  its  intro- 
duction, care  being  had  not  to  exert  too  great  a  pressure 
and  thus  rupture  the  vaginal  vault.  In  order  to  evacuate 
the  bladder  it  is  sometimes  necessary  to  raise  the  vaginal 
portion  of  the  cervix  and  push  it  away  from  the  symphy- 
sis. In  gradual  reposition  by  elastic  pressure  Sims's 
lateral  or  the  knee-elbow  position  is  sometimes  employed 
(Fig.  63).  Up  to  the  sixth  month  the  organ  may  be 
kept  in  position  by  a  lever-pessary  or  by  means  of  around 
smooth  ring. 

If  reposition  is  impossible,  even  under  anesthesia  and 
after  dilatation  with  the  colpeurynter,  and  if  the  urine 
becomes  bloody  and  begins  to  decompose,  puncture  of  the 
bladder  should  be  performed  ;  as  there  is  danger  of  the 
connective  tissue   surrounding  the  bladder  becoming  in- 


4 


s 


DISTUBBA^X'ES  DUBIXG   PREGNANCY.  173 

filtrated  with  uriiK^  it  is  best  to  open  the  viscus  through 
the  vagina  ;  or  premature  labor  should  be  induced  with 
a  sound  or  a  curved  bougie ;  or,  if  the  os  cannot  be 
reached,  the  ovum  is  punctured  through  the  posterior 
vaginal  and  uterine  wall  ;  or,  in  extreme  cases,  Cesarean 
section  through  the  vagina  under  absolute  asepsis.  In 
exceptional  cases  it  may  be  possible  to  preserve  the  ovum 
by  replacing  the  uterus  through  an  abdominal  section. 
Forced  reposition  may  lead  to  rupture  of  the  gangrenous 
bladder  and  fatal  peritonitis. 

(«)  Prolapse  of  the  gravid  uterus  occurs  only  in  the 
first  half  of  pregnancy ;  incomplete  prolapse,  due  to 
hypertrophy  of  the  cervix — in  which  the  fundus  of  the 
uterus,  as  a  rule,  occupies  the  usual  positions  at  the 
various  periods  of  pregnancy,  being  pushed  upward  by 
the  tension  of  the  vaccinal  walls  and  held  above  the 
superior  strait  by  its  own  dilatation — may  develop  during 
pregnancy,  but  in  most  cases  the  condition  is  present  be- 
fore pregnancy  occurs.  Prolapse  may  also  be  caused  by 
ovarian  tum  )rs  without  hypertrophy  of  the  cervix  (see 
Fig.  109),  or  it  may  be  brought  about  by  external 
mechanical  influences,  such  as  cough  or  violent  bearing 
down,  when  the  suspensory  apparatus  of  the  uterus  is 
weak. 

In  one-third  of  all  the  cases  prolapse  does  not  occur 
until  the  onset  of  labor  ;  for  instance,  it  may  imme- 
diately follow  a  labor-pain  when  the  lower  uterine  seg- 
ment is  rigid  and  very  resistant.  It  is  never  due  to  ab- 
normal size  of  the  pelvis  or  of  the  vulvar  opening  unless 
the  floor  of  the  perineum  is  weakened.  A  special  variety 
of  prolapse  consists  in  the  descent  of  the  edematous  and 
markedly  hyperemic  swollen  anterior  lip  of  the  external  os, 
without  anatomical  elongation,  into  or  beyond  the  vulva. 

In  those  cases  in  which  the  uterus  supports  itself  above 
the  superior  strait  during  the  second  half  of  pregnancy, 
postpartum  prolapse  is  very  apt  to  occur. 

The  relaxation  of  the  pelvic  organs  not  only  gives  rise 
to  descent  and  prolapse  of  the   uterus,  but  is  a  frequent 


174      THE  PATHOLOGY  OF  PREGNANCY. 

cause  of  premature  expulsion  of  the  ovum.  Prolapse 
itself  predisposes  to  abortion  on  account  of  the  distortion 
and  consequent  disturbances  to  the  circulation. 

For  these  reasons  the  condition  requires  treatment 
during  pregnancy,  the  best  procedure  being  the  introduc- 
tion of  a  Mayer's  hard-rubber  or  celluloid  ring-pessary, 
which  is  left  in  place  until  the  sixth  or  eighth  month,  or 
a  plastic  operation  for  prolapse  may  be  performed.  In  a 
number  of  cases  of  so-called  habitual  abortion  without 
marked  prolapse  of  the  uterus,  but  with  descent  of  the 
uterus  w^hich  was  retroverted  in  the  non-gravid  state, 
owing  to  weakness  of  the  suspensory  and  circulatory  ap- 
paratus (chronic  congestions  and  stasis),  the  author  has 
seen  this  treatment  followed  by  normal  delivery  of  the 
child  at  term  and  relief  of  all  the  symptoms  which  had 
marked  previous  pregnancies.  Abortion  and  premature 
delivery  are  very  apt  to  bring  on  septic  endometritis  on 
account  of  the  lacerated  condition  of  the  external  os. 

(6)  Anteflexion  of  the  uterus  is  of  no  special  significance 
unless  it  is  associated  with  pendulous  abdomen  or  depends 
on  inflammatory  or  operative  wounds  resulting  in  peri- 
metritic adhesions  or  fixations  (hysteropexy,  vaginal  and 
vesical  fixation,  ventral  fixation),  which  render  the  organ 
absolutely  immovable. 

Since  B.  S.  Schultze's  investigations  we  know  that  the 
non-gravid  uterus  is  normally  inclined  forward,  and  in 
vigorous  organs,  especially  such  as  have  already  borne 
children,  a  slight  anteflexion  is  added.  During  the  first 
months  of  gestation  this  anterior  position  of  the  organ 
becomes  accentuated  on  account  of  its  increase  in  size  and 
weight,  as  may  be  observed  at  each  menstruation  ;  the 
body  of  the  uterus  sinks  deeper  into  the  bladder,  so  to 
speak,  the  portio  vaginalis  rises,  and  the  whole  organ  ap- 
pears "tipped  over"  forward.  Even  in  cases  of  retro- 
flexion ])regnancy  nearly  always  effects  a  spontaneous 
replacement  and  anterior  flexion  of  the  uterus  or,  if  the 
posterior  wall  is  fixed  by  perimetritic  adhesions  or  by 
tumors,  anteflexion  with  posterior  sacculation  takes  place. 


niSTUBBAKCES  DURIXG  PREGNANCY.  175 

When  the  abdominal  walls  are  relaxed  this  tipping 
over  forward  is  desio^nated  as  an  excessive  ''anteversio- 
flexio  uteri  "  with  pendulous  abdomen,  a  condition  which 
may  give  trouble  in  many  Avays  and  may  even  form  a 
serious  complication  of  labor. 

The  condition  occurs  most  frequently  in  flat  or  antero- 
posteriorly  contracted  pelves,  partly  because  the  weight 
of  the  gravid  uterus  is  not  sufficiently  supported  by  the 
anterior  pelvic  wall  and  partly  because  such  a  pelvic 
deformity  is  usually  found  in  hard-working,  badly  nour- 
ished individuals  with  defective  nervous  tone,  who  had 
been  rachitic  in  earlv  life.  As  a  result  the  mobilitv  of 
the  uterus  is  much  increased,  and  in  some  cases  there  is  a 
distinct  flattening  due  to  flaccidity  or  oblique  distortion 
with  a  corresponding  attitude  of  the  fetus  up  to  the 
moment  of  labor  and  even  during  its  progress.  The 
diminution  in  the  available  space,  especially  of  the  true 
pelvis  in  contracted  pelves  and  the  shortening  of  the 
abdominal  cavity  in  scoliosis,  also  predis])oses  to  ante- 
flexion of  the  uterus.  The  same  may  be  said  of  marked 
lumbosacral  lordosis  in  rachitic  women  and  of  transversely 
contracted,  oval  pelves  during  the  first  months  of  preg- 
nancy, because  the  symphysis  is  displaced  forward  and  the 
fundus  of  the  uterus  thereby  loses  its  normal  support. 

The  predisposing  factors  in  the  abdominal  walls  are  a 
relaxed  condition,  separation  of  the  recti  muscles,  diminu- 
tion in  the  thickness  of  the  fascite  and  of  the  panniculus 
adiposus ;  those  on  the  part  of  the  ovum  are  hydramnion 
and  twin  pregnancies. 

During  the  first  half  of  pregnancy  the  fundus  is  still 
supported  by  the  symphysis,  the  portio  vaginalis  being 
directed  posteriorly.  A  true  pathological  fixation  in  ante- 
flexion can  exist,  or  at  least  continue  to  exist,  only  when 
there  is  some  form  of  abnormal  fixation.' 

^It  is  to  be  remarked  in  tliis  connection  that  the  body  of  the  uterus 
normally  descends  durinor  the  first  two  months  on  account  of  its  in- 
creased weight  (Figs.  19  and  33),  and  thus  forms  an  obtuse  angle  with  the 
cervix.  This  phenomeuon  occurs  again  toward  the  end  of  pregnancy 
when  the  head  enters  the  true  pelvis  (see J  1,  ad  finem). 


176      THE  PATHOLOGY  OF  PREGNANCY. 

During  the  second  half  of  pregnancy  the  fundus  pro- 
jects beyond  the  symphysis,  forming  either  an  obtuse 
angle  with  the  anterior  pelvic  wall  (first  degree  of  pendu- 
lous abdomen,  Fig.  128)  or  a  right  angle,  so  that  the 
navel  forms  the  most  prominent  part  of  this  so-called 
"conical  abdomen  "  (second  degree,  Fig.  127) ;  or  it  may 
make  an  acute  angle,  so  that  the  fundus  uteri  stands  at 
the  same  level  as  the  portio  vaginalis  or  even  lower  (third 
degree.  Figs.  99  and  129),  and  the  abdomen  rests  on  the 
thighs  when  the  woman  is  sitting  down,  or,  in  extreme 
cases,  when  she  is  in  the  upright  position. 

In  the  case  of  abnormal  inflammatory  adhesions,  resist- 
ing even  the  softening  influences  of  pregnancy,  especially 
an  excessively  high  anterior  vaginal  fixation  of  the  uterus 
secondary  to  an  operation,  the  anterior  uterine  wall  may 
remain  rigid  and  unyielding  and  the  ovum  thus  develop 
entirely  within  the  posterior  wall,  which,  unless  the  ovum 
is  prematurely  expelled,  undergoes  an  alarming  degree  of 
dilatation  and  presents  the  picture  of  partial  retroflexion  of 
the  gravid  uterus.  This  condition  may  occur  even  with- 
out the  existence  of  abnormal  adhesions  in  simple  retro- 
version of  an  anteflexed  uterus  during  the  last  months  of 
pregnancy,  on  account  of  the  head  developing  within  the 
posterior  lower  uterine  segment,  especially  if  the  abdomen 
is  pendulous  ;  in  these  cases  the  portio  vaginalis  is  forced 
against  the  symphysis.  Abortions  have  been  repeatedly 
observed  after  hysteropexy.  Abnormal  fixations  also  lead 
to  torsions  through  a  quarter  of  a  circle  and  to  lateroflex- 
ions  with  secondary  sacculations. 

Another  symptom  which  has  been  repeatedly  men- 
tioned and  again  discarded  by  various  authors  as  follow- 
ing a  marked  anteflexion  of  the  uterus  (with  or  without 
occasional  incarceration  at  the  symphysis  or  partial  con- 
vulsive contractions)  is  hyperemesis  gravidarum. 

I  have  convinced  myself  of  the  occurrence  of  this 
symptom  in  various  instances,  and  always  in  hystero- 
neurasthenic  and  anemic  individuals  with  infantile  ante- 
flexion of  the  uterus,  which  I  had  observed  to  be  present 


TUMORS.  Ill 

in  them  before  marriage  ;  that  is  to  say,  the  imperfectly 
developed  body  of  the  uterus  formed  an  acute  angle  with 
the  long,  thin  cervix,  Vvhose  axis  corresponded  with  the 
long  axis  of  the  vagina.  Such  women  usually  suffer  from 
colic  due  to  dysmenorrhea  even  before  they  become 
pregnant. 

(c)  A  rare  anomaly  is  hernia  of  the  gravid  uterus  or  hysterocele, 
which  may  also  be  easily  mistaken  for  an  ectopic  gestation.  The 
gravid  uterus  may  be  found  in  an  inguinal  or  in  a  ventral  hernia 
or  even  in  the  sac  of  a  femoral  hernia.  So  far  as  has  been  ob- 
served, gestation  is  not  interrupted  by  an  inguinal  hernia,  but 
neither  does  spontaneous  reposition  or  natural  delivery  take  place 
in  that  condition.  The  head  of  the  fetus  usually  lies  toward  the 
mouth  of  the  hernia,  showing  that  the  position  of  the  child  de- 
pends on  the  configuration  of  the  uterus. 

The  uterus  may  undergo  secondary  distortion  within  the  hernial 
sac ;  a  few  cases  of  this  kind  are  congenital,  especially  in  uterus 
bicornis  or  unicornis.  Tubal  pregnancies  in  inguinal  hernia  are 
very  rare  (Jordan's  case  in  Heidelberg). 

To  establish  the  diagnosis  it  is  necessary  to  prove  a  connection 
between  the  portio  vaginalis  and  the  tumor  within  the  hernial  sac. 
The  palpation  of  fetal  parts  within  the  latter  establishes  the  diag- 
nosis of  pregnancy. 

Treatraent. — Eeduction,  or  else  induction  of  abortion.  Cesarean 
section,  or  herniotomy  and  removal  of  the  uterus  or  of  the  gravid 
cornu,  as  in  v.  Winckel's  case,  which  is  illustrated  in  Fig.  104, 
or  of  the  tubal  sac  (Jordan),  or  dilatation  of  the  hernial  opening 
with  the  knife  (P.  Miiller). 

I  i6.  TUM0R5. 

Tumors  which  encroach  upon  the  true  pelvis,  whether 
they  emanate  from  the  genital  or  from  neighboring  organs, 
or  enter  the  superior  strait  like  movable  kidneys  or  hydro- 
nephrosis, may  give  trouble  even  during  pregnancy. 

(a)  Fibromyoma. — Fibromyoma  of  the  uterus,  rarely  of 
the  vagina,  is  much  less  frequently  met  with,  either  in  the 
pregnant  or  in  the  puerperal  woman,  than  the  experience 
of  gynecological  practice  would  lead  us  to  expect.  The 
reason  is  not  so  much  that  a  woman  with  a  tendency  to 
have  tumors  is  less  apt  to  become  pregnant,  but  that 
the  tumors  do  not,  as  a  rule,  develop  before  the  thirty- 
fifth  year  or  toward  the  end  of  the  child-bearing  period. 

12 


178  THE  PATHOLOGY  OF  PREGNANCY. 

Most  tumors,  especially  the  smaller  ones,  are  not  diag- 
nosed during  pregnancy,  although,  on  the  other  hand, 
large  tumors  have  occasionally  led  to  the  diagnosis  of 
twins.  If  a  tumor  does  make  itself  felt  during  pregnancy 
or  parturition  the  prognosis  is  very  grave,  both  for  the 
mother  and  for  the  child  ;  hence,  if  during  pregnancy  we 
discover  a  tumor  whose  size  and  position  render  it  danger- 
ous in  itself  or  in  connection  with  parturition,  or  cause 
alarming  symptoms,  say,  in  the  peritoneum,  the  kidneys, 
the  lungs,  and  the  heart,  removal  of  the  tumor  alone,  or, 
during  the  earlier  months  of  pregnancy,  of  the  entire 
uterus,  is  indicated. 

Myomata  on  the  posterior  wall  of  the  gravid  uterus 
may  by  their  weight  give  rise  to  retroversion  and  incar- 
ceration of  the  organ  under  the  promontory  and  lead  to 
abortion  or  to  the  same  symptoms  which  we  have  learned 
in  connection  with  retroflexion  and  incarceration  of  the 
gravid  uterus  (retention  of  the  urine).  In  either  condi- 
tion spontaneous  replacement  is  impossible. 

In  pedunculated,  movable,  subserous  myomata  we  may 
have  torsion  of  the  pedicle  leading  to  necrosis  of  the 
tumor,  to  adhesions  with  loops  of  intestine,  and  eventually 
to  peritonitis.  In  the  same  way  a  large  intramural  tumor 
may  undergo  softening  and  decomposition  and  thus  bring 
about  further  infection  of  the  organism  and  peritonitis. 
This  condition,  like  the  rapid  growth  of  a  tumor  during 
pregnancy,  gives  rise  to  marked  symptoms  and  calls  for 
immediate  operative  interference.  The  nearer  a  subserous 
tumor  lies  to  the  cervix,  the  greater  the  probability  of  its 
becoming  troublesome. 

Fibromyoma  is  a  tumor  consisting  of  muscular  and  connective 
tissue,  the  latter  undergoing  marked  proliferation  as  the  tumor 
grows.  The  tumor  originates  in  the  muscular  wall  of  the  uterus 
or  vagina,  that  is  to  say,  it  is  at  first  intramural  (intraparietal), 
beginning  in  the  muscular  layer  of  the  body  of  the  uterus  and 
extending  either  toward  the  mucosa  or  toward  the  serous  surface, 
or  becoming  iutraligamentary,  that  is,  growing  between  the  two 
layers  of  the  broad  ligament,  or,  finally,  sinking  into  the  cervix. 
A  projecting  tumor  may  eventually  draw  out  a  vascular  pedicle, 


TUMORS.  179 

in  other  words,  may  become  polypoid.  This  variety  includes 
particularly  the  fibrous  polyps  which  mav  attain  a  very  consider- 
able size  (as  large  as  a  child's  or  a  man's' head),  in  contradistinc- 
tion to  the  small,  soft,  mucous  polyps,  consisting  only  of  the 
elements  of  the  mucous  membrane.  The  latter  may  'occur  in 
connection  with  fibromata,  as  the  mucous  membrane  always  tends 
to  proliferate  with  both  submucous  and  intramural  myomata. 
From  this  swollen,  hypertrophied,  and  fungous  endometrium 
originate  the  profuse  menorrhagias  and  metrorrhagias  which  form 
the  characteristic  symptoms  of  uterine  mvoma  in  the  non-preo*- 
nant  state.  "  ° 

The  effect  of  a  fibromyoma  on  pregnancy  consists  in 
premature  expulsion  of  the  ovum,  deformity  of  the  fetus, 
abnormally  low  insertion  of  the  placenta,'  not  far  from' 
and  just  above  the  internal  os  (placenta  pr^evia),  or,  rarely, 
ectopic  gestation  with  severe  subjective  symptoms. 

The  tumors  act  (1)  by  diminishing  the  space,  (2)  by 
producing  retroversion  of  the  uterus,  and  (3)  by  setting 
up  circulatory  disturbances  and  the  above-mentioned 
structural  changes  in  the  endometrium,  which  continue 
after  the  mucous  membrane  has  been  converted  into 
decidua. 

As  a  result  of  these  changes,  rarelv  from  metrorrhao-ia 
alone,  abortion  occurs,  or  else  the  fetus  dies  and  leads^o 
premature  labor,  which  often  becomes  habitual.  It  must 
be  remembered  that  this  accident,  which  occurs  in  15  to 
20  per  cent,  of  the  cases,  is  often  followed  bv  retention 
of  portions  of  the  fetal  membranes ;  hence,  careful  cu- 
rettage should  never  be  nedected.  As  a  result  of  the 
encroachment  of  the  tumor  the  child  is  unable  to  develop 
(deformity,  see  Fig.  108),  or  the  ovum  becomes  attached 
in  an  abnormal  location  :  in  the  lower  uterine  seo^ment,  as 
in  the  case  of  placenta  prsevia,  which  is  so  often'observed 
with  submucous  myomata,  or  in  the  tube  in  the  form  of 
an  extra-uterine  pregnancy,  either  because  the  uterine 
orifice  of  the  tube  is  too '  small  for  the  passage  of  the 
impregnated  ovum  or  because  its  progress  toward  the 
uterus  is  obstructed  by  the  inflammation  and  swelling  of 
the  mucous  membrane. 

Failure  of   conception   is   sometimes  explained  bv  the 


180      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  106.  A  Fibromyoma,  springing  from  the  lower  uterine  segment  and 
posterior  wall  of  the  cervix,  fills  up  the  true  pelvis  and  blocks  the  su- 
perior strait  so  that  the  head  cannot  enter  the  pelvis.  The  head  becomes 
displaced  forward  and  permits  the  hand  to  prolapse ;  that  is,  to  slip 
under  it  into  the  anterior  pole  of  the  amniotic  sac.  The  head  is  forced 
down  upon  the  symphysis.  The  body  of  the  tumor  completely  fills  the 
lateral  half  of  the  pelvis.  If  the  condition  is  allowed  to  go  on  until 
parturition,  it  may  lead  to  lateral  deviation  of  the  head  against  the  body 
of  the  iliac  bone,  to  face  presentation,  or  to  oblique  position  of  the  fetus. 


presence  of  submucous  and  interstitial  or  polypoid  and 
cervical  myoniata,  both  on  account  of  the  structural 
changes  and  active  secretion  and  hemorrhages  of  the 
hypertrophied  mucous  membrane,  and  on  account  of  the 
mechanical  blocking  of  the  cavity  of  the  uterus  and  of 
the  internal  os.  Large  subserous  tumors  may  have  the 
same  effect  by  causing  displacement  or  acute  flexion  of 
the  adnexa  (Fallopian  tubes,  ovaries). 

This  form  of  sterility  is,  therefore,  the  result  of  myo- 
matosis. It  is  probable  that  there  is  also  some  primary 
cause  for  the  development  of  myomata  and  for  this  abso- 
lute or  relative  sterility,  but  the  connection  has  never 
been  proved.  It  could  not,  in  any  event,  be  regarded  as 
a  law  governing  each  individual  case,  but  rather  as  a  more 
or  less  frequent  combination  of  co-existent  symptoms  of 
degeneration. 

Among  the  effects  of  pregnancy  on  the  growth  of  myo- 
mata we  have  already  mentioned  :  first,  the  rising  of  the 
tumor  and  its  incarceration  below  the  promontory,  condi- 
tions which  have  been  found  after  the  death  of  the  child 
at  the  end  of  pregnancy  ;  second,  torsion  of  the  pedicle 
with  secondary  softening  and  necrosis ;  third,  necrosis  due 
to  disturbances  of  the  circulation  or  to  hemorrhages  (ten- 
dency to  thrombosis  of  the  veins  of  the  adnexa) ;  and, 
fourth,  rapid  growth  of  the  tumors. 

The  latter  is  due  not  so  much  to  the  increase  in  the 
number  and  size  of  the  fibers  as  to  a  serous  infiltration  or 
edema  which  rapidly  subsides  during  the  puerperium ; 
the  fibrous  elements  show  the  greatest  degree  of  prolifera- 


Tab.  49. 


>- 


Fig.   106 


l.ilh.AnMi    F  'RuirJihnfri     yiir.rhnr. 


TUMORS.  181 

tioii.  Xiimerical  increase  of  the  muscular  fibers  is  ob- 
served only  in  true  intramural  tumors. 

Fifth,  the  shape  of  the  tumor  adapts  itself  to  the  wall 
which  forms  its  native  soil,  and  therefore  depends  on  the 
degree  of  distention  ;  in  most  cases  it  becomes  flattened 
and  increased  in  its  long  diameter.  This  process  may 
often  give  rise  to  central  hemorrhagic  or  softening  foci, 
which  present  a  fruitful  soil  for  the  development  of  infec- 
tious germs  (sloughing). 

Sixthj  a  special  form  of  displacement  of  the  tumor 
consists  in  the  loosening  of  the  polypoid  submucous  or 
cervical  myomata  from  their  foundations  and  subsequent 
expulsion — the  so-called  birth  of  the  tumor. 

The  diagnosis  of  a  pregnancy  complicated  by  the 
presence  of  a  tumor  is  often  very  difficult.  Small  tumors, 
as  a  rule,  either  escape  detection  or  pass  for  fetal  portions, 
or  they  may  even  lead  to  the  diagnosis  of  twin  pregnancy. 
Large  tumors  are  usually  recognized  without  difficulty  on 
account  of  their  hardness,  but  not  so  the  co-existing  preg- 
nancy, especially  during  the  earlier  months.  In  cases  of 
intramural,  cervical,  and  multiple  myomata  there  is  un- 
fortunately an  entire  absence  of  Hegar's  sign,  or  doughy 
consistency  of  the  uterine  wall  about  the  internal  os,  and 
of  the  usual  softness  and  lack  of  resistance  to  the  finger 
of  the  body  of  the  uterus.  The  entire  list  of  probable 
signs  of  preguancy  must  be  reviewed  and  the  presence  of 
a  soft  tumor  containing  the  fetus  in  juxtaposition  to  the 
hard  myoma  must  be  determined  under  anesthesia  before 
the  diagnosis  can  be  established.  It  is  to  be  remembered 
that  the  gravid  uterus  may  be  below  and  behind  the 
tumor,  and  in  such  a  case  the  body  of  the  uterus  with  its 
contents  can  be  palpated  with  the  finger  introduced  into 
the  rectum. 

The  diagnosis  is  often  obscured  by  softening  of  the 
tumor  simulating  fluctuation,  and  by  the  fact  that  on  the 
one  hand  the  presence  of  a  tumor  alone  is  sometimes  suf- 
ficient to  cause  mammary  secretion,  and,  on  the  other 
hand,  more  or  less  copious  periodical  hemorrhages  may 


182      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  107.  First  Face  Presentation  due  to  au  obstructing  myoma  of  tlie 
cervix  which  has  become  detached  from  the  wall  and  been  "born" 
before  the  child  (placenta  prsevia  marginalis). 

Fig.  108.  An  Enormous  Subserous  Uterine  Myoma  prevents  the  en- 
trance of  the  fetus  into  the  true  pelvis  and  gives  rise  to  au  abnormal 
presentation  and  attitude;  deformities  due  to  protracted  diminution  of 
the  space  and  compression.  (Both  original  drawings;  Fig.  108  after  a 
specimen  in  the  Munich  Gynecological  Clinic.) 


persist  in  spite  of  the  existing  pregnancy.  While  in 
most  cases  repeated  examinations  with  a  view  of  deter- 
mining the  true  nature  of  a  tumor  simulating  pregnancy 
and  of  the  rapid  growth  of  one  of  the  tumors  or  of  the 
entire  mass,  with  the  typical  concomitant  symptoms, 
usually  enable  the  examiner  to  arrive  at  a  satisfactory 
conclusion,  it  occasionally  happens  that  without  incising 
the  uterus  a  diagnosis  cannot  be  reached  even  after  the 
abdominal  cavity  has  been  opened. 

The  treatment  during  pregnancy  follows  naturally 
from  the  diagnosis  and  from  the  prognosis,  it  being  re- 
membered that  the  latter  is  to  include  the  probable  effects 
of  labor  and  a  consideration  of  the  best  methods  to  pre- 
serve the  life  of  the  child.  Hence  the  proper  estimation 
of  such  cases  is  of  the  utmost  importance  for  every 
physician.     We  have  the  following  possibilities  before  us  : 

1.  Inaction  following  the  development  of  events  suh 
partu,  "armed  expectancy." 

2.  Inaction  until  labor-pains  have  begun. 

3.  Inaction  until  the  child  has  become  viable  :  (a)  in- 
duction of  premature  labor ;  (b)  Cesarean  section,  either 
to  be  preceded  or  followed  by  removal  of  the  tumor  or  of 
the  uterus. 

4.  Inaction  until  the  advent  of  violent  subjective  symp- 
toms or  until  there  is  imminent  danger  to  the  woman's 
life  (by  infection,  especially  in  thrombosis) ;  then, 

5.  Inaction,  attempt  at  reposition. 

6.  Immediate  removal  of  the  tumor  during  the  first 
months  without  interrupting  pregnancy :  (a)  through  the 
vagina  (removal   of  polypi,  enucleation  of  cervical  myo- 


o 


TUMORS.  183 

mata) ;  (h)  by  celiotomy  (removal  of  subserous  polypi), 
myomectomy. 

7.  Supravaginal  amputation  of  the  gravid  uterus  by 
abdominal  section  during  the  first  months. 

8.  Total  extirpation  of  the  gravid  uterus. 

9.  Induction  of  premature  labor  or  abortion^  followed 
either  immediately  or  later  by  removal  of  the  myoma,  or 
without  such  removal. 

The  prognosis  of  myomectomy  during  pregnancy  is  not 
very  encouraging  :  20  per  cent,  maternal  and  45  per  cent, 
fetal  mortality.  On  the  other  hand,  Stavely^s  statistics 
of  five  hundred  and  ninety-seven  non-operated  cases  yield 
a  death-rate  of  37  per  cent. 

If  a  myoma  is  discovered  during  the  early  months  of 
pregnancy  the  first  question  should  be  :  ^^  Are  there  any 
marked  subjective  symptoms  ?  '^ ;  the  second  :  "  Are  such 
symptoms  to  be  expected  before  the  child  becomes 
viable  ?  '^  ;  and  the  third  :  '^  AYill  the  advent  of  labor  at 
term  give  rise  to  dangers  which  at  that  time  will  be  prac- 
tically insurmountable  ;  in  other  words,  endanger  the  life 
of  both  mother  and  child  ;  is  the  immediate  removal  of 
the  tumor  less  dangerous  than  a  subsequent  removal  would 
be?" 

To  answer  these  questions  w^e  need  an  exact  knowledge 
not  only  of  the  condition  of  aflPairs  at  the  time  and  of  the 
general  condition  of  the  mother,  but  of  the  behavior  dur- 
ing pregnancy  and  parturition  of  the  particular  variety  of 
myoma  present.  To  settle  this  point  the  above-mentioned 
data  are  of  the  highest  value. 

The  first  things  to  be  considered  are  the  size  and  situa- 
tion of  the  tumor. 

Small  tumors  within  the  body  of  the  uterus  should 
never  be  interfered  with,  although  they  may  produce  post- 
partum hemorrhage  during  the  puerperium. 

Cervical  jyolypi  are  to  be  removed  at  once.  Broad 
cervical  tumors  seated  within  the  wall  are  best  let  alone 
until  the  beginning  of  labor,  as  their  enucleation  is  very 
apt  to  give  rise  to  profuse  hemorrhages  and  other  alarm- 


184  THE  PATHOLOGY  OF  PREGNANCY. 

ing  symptoms,  and  to  abortion.  The  same  is  true  of  all 
submucous  myomata.  The  gaping  wound  which  remains 
after  their  removal  always  involves  great  danger  of  hem- 
orrhage or  infection,  either  before  or  after  expulsion  of 
the  ovum.  Enucleation  itself  is  quite  easy  on  account 
of  the  relaxed  condition  of  the  tissues. 

In  large  myomata  situated  in  the  cervix  the  possibility 
of  immediate  or  subsequent  replacement  is  first  to  be  con- 
sidered. 

As  in  all  the  following  large  varieties  of  myomata  we 
must  remember  first  of  all  the  law  that  a  tumor,  on  the 
one  hand,  grows  very  rapidly  during  pregnancy,  while, 
on  the  other  hand,  its  form  tends  to  adapt  itself  to  the 
growth  of  the  uterus,  that  is,  the  tumor  becomes  flattened 
and  increased  in  its  long  diameter,  so  that  the  rising  of 
the  gravid  uterus  into  the  abdominal  cavity,  assisted  by 
the  labor-pains,  may  suffice  to  draw  the  softened  tumor 
above  the  superior  strait  even  in  cases  in  which  unsuccess- 
ful attempts  at  reposition  have  been  made  under  anesthe- 
sia, and  that  thus  the  head  or  the  breech  may  be  permitted 
to  engage.     This  is  an  important  point  to  remember. 

If  the  true  pelvis  is  blocked  by  a  large  cervical  myoma 
no  attempt  at  reposition  must  be  made  before  the  eighth 
month  of  pregnancy,  on  account  of  the  danger  of  abortion, 
unless  symptoms  of  incarceration  make  their  appearance. 
After  that  period,  however,  and  especially  at  the  onset  of 
labor,  reposition  must  be  performed  under  all  circum- 
stances (if  necessary  in  the  lateral  or  knee-elbow  position 
through  the  vagina  and  rectum  ;  see  methods  of  reposition 
in  retroflexio  uteri,  §§15  and  20). 

If  reposition  of  the  tumor  is  impossible,  and  if  it  ap- 
pears to  be  so  tightly  wedged  in  that  the  uterus  will  in 
all  probability  not  be  able  to  draw  it  upward,  it  must  be 
removed  through  an  abdominal  section.  The  question 
whether  spontaneous  reposition  is  likely  to  take  place  is 
extremely  difficult  to  decide. 

The  treatment  of  subserous  myomata  wedged  into 
the  true  pelvis  underneath  a  gravid  uterus  is  subject  to 


TUMORS.  185 

the  same  considerations  ;  since  the  possibility  of  sponta- 
neous or  artificial  reposition  is  greatest  in  these  cases  the 
induction  of  premature  labor  is  adapted  to  them.  The 
indications  for  this  procedure  are  the  same  as  in  contracted 
pelves.  As,  owing  to  the  rigidity  of  the  structures  and 
the  interference  of  the  myoma  with  the  strength  and  regu- 
larity of  the  contractions,  there  is  frequently  insufficient 
dilatation  of  the  cervical  canal  and  of  the  lower  uterine 
segment,  podalic  version  is  to  be  preferred  in  such  cases 
on  account  of  its  dilating  action  on  the  cervix. 

If  portions  of  fetal  membranes  are  retained,  or  sepsis 
develops  after  abortion  or  parturition  (metrophlebothrom- 
bosis),  and  should  intra-uterine  irrigation  and  curettage 
prove  unavailing,  immediate  total  extirpation  is  indicated. 

The  '^  ideal  moment  '^  for  myomectomy  through  an 
abdominal  incision  is  the  end  of  pregnancy,  because  the 
life  of  the  child  is  thus  preserved  and  the  danger  to  the 
mother  is  not  materially  increased,  as  the  greater  size  and 
vascularity  of  the  tumor  are  counterbalanced  by  its 
accessibility  and  the  facility  with  which  it  can  be  enucle- 
ated. Kemoval  of  pedunculated  subserous  myomata  is 
more  justifiable  because  less  apt  to  bring  on  an  abortion 
than  enucleation. 

Myomectomy  by  celiotomy  is  indicated  in  the  case  of 
larger  subserous,  intraligamentary,  or  intramural  tumors, 
and  in  large  myomata  of  the  cervix,  whenever  their 
growth  or  position,  or  the  occurrence  of  softening,  threaten 
to  make  them  troublesome.  Immediate  operation  is  in- 
dicated only  by  the  presence  of  intense  subjective  symp- 
toms or  imminent  danger  to  life,  such  as  twisting  of  the 
pedicle,  irremediable  incarceration,  peritonitis,  suppura- 
tion, and  complicating  organic  diseases  that  typically 
accompany  myomata  (diseases  of  the  heart,  lungs,  and 
kidneys). 

In  cases  of  this  kind  supravaginal  amputation  of  the 
gravid  uterus  without  evacuation  is  to  be  considered  as 
long  as  the  fetus  is  not  viable  ;  after  the  eighth  month 
Cesarean  section  should  be  performed,  followed  by  Porro's 


186      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  109.  Total  Prolapse  of  Retroflexed  Gravid  Uterus,  due  to  pressure 
of  a  large  pedunculated  ovarian  cyst  on  the  left  side,  completely  filling 
the  true  pelvis  and  reaching  to  the  navel  above;  ischuria;  rectocele. 

Fig.  110.  Transverse  Rupture  of  the  Uterus  {Ru.),  due  to  thinning 
of  the  wall  by  a  cancerous  ulcer  of  the  cervix  ([/"^c.) ;  anteflexio  uteri 
puerperalis ;  PL,  placental  site  ;  C.B.,  contraction-ring  ;  A.Mm.,  external 
OS  (the  preparation  is  shown  in  sagittal  section). 

amputation.  The  stump  is  best  disposed  of  by  return- 
ing it  into  the  peritoneal  cavity.  If  the  fetus  is  dead  at 
this  time,  total  extirpation  without  opening  the  uterus  is 
often  more  advisable.  Cesarean  section  alone  is  very 
dangerous  and  cannot  be  considered  a  rational  mode  of 
treatment.  Total  extirpation  is  more  dangerous  on 
account  of  the  greater  technical  difficulty  (although  this  is 
not  always  the  case),  the  longer  duration  of  the  operation, 
and  the  necessity  of  opening  the  vagina.  On  the  other 
hand,  this  operation  gives  the  best  hope  when  infection 
already  exists,  as  well  as  with  tumors  which  are  so  deep- 
seated  that  the  vagina  would  in  any  case  have  to  be 
opened,  as  in  large  myomata  of  the  cervix. 

(6)  Ovarian  Tumors. — Like  certain  myomata  of  the 
uterus,  ovarian  tumors  often  interfere  with  conception, 
but  ovarian  cysts  do  not  show  the  same  tendency  to  rapid 
growth  during  gestation  ;  much  more  frequently  they 
begin  to  grow  after  postpartum  congestion  is  established. 
As  intimated  at  the  beginning  of  this  section  ovarian 
tumors  rarely  accompany  pregnancy,  although  evidently 
not  because  of  any  sterility  of  the  ovarian  tissue  due  to 
the  presence  of  the  neoplasm,  since  cases  of  large  bilateral 
ovarian  tumors  accompanying  pregnancy  have  been  re- 
ported. 

Although  pregnancy  and  parturition  have  occasionally 
been  brought  to  a  successful  termination,  yet  the  danger 
is  so  great  as  to  constitute  an  absolute  indication  for  the 
immediate  removal  of  the  tumor  as  soon  as  the  diagnosis 
is  established. 

As  the  fundus  of  the  uterus  rises  in  the  abdominal 
cavity  it  exerts  a   marked  traction  on  the  stalk  of  the 


f^ 


O 


TUMORS.  187 

tumor,  the  insertion  of  Avliicli  becomes  relatively  more 
and  more  deep,  and  thus  circuhitory  disturbances  are  pro- 
duced. In  other  cases  the  uterus  has  a  tendency  to  rotate 
the  tumor  and  jiroduce  a  fatal  torsion  of  the  pedicle 
which  is  followed  by  necrosis  and  peritonitis;  finally,  if 
the  wall  of  the  tumor  is  brittle,  the  direct  pressure  on  it 
may  cause  it  to  rupture.  If  the  tumor  is  small  it  may 
remain  within  the  true  ])elvis  under  the  promontory  and 
thus  block  the  entrance  of  the  head  when  labor  sets  in ; 
this  complication  is  particularly  apt  to  occur  in  cases  of 
massive  ovarian  fibromata,  which,  although  fortunately 
rare,  show  a  marked  tendency  to  attain  this  fatal  medium 
size. 

Conversely,  the  tumor  may  be  wedged  in  the  superior 
strait  and  retain  the  uterus  in  a  position  of  retroflexion 
and  incarceration,  or  it  may  lead  to  incarceration  of  the 
uterus  and  thus  bring  on  abortion.  The  latter  may  also 
occur  without  a  complicating  retroflexion. 

The  diagnosis  of  this  complication  must  be  made 
early,  and  it  is  therefore  of  the  greatest  importance  for 
every  physician  to  be  able  to  recognize  the  condition  with 
certainty.  The  complication  is  productive  of  great 
danger  both  during  pregnancy  and  during  parturition, 
and  it  is  usually  accompanied  early  by  marked  subjective 
symptoms.  The  usual  symptoms  of  pregnancy  are  in- 
tensified and  early  become  recognizable  on  account  of  the 
marked  pressure,  as  in  twin  pregnancies.  To  these  are 
added  the  discomfort  of  the  tumor  itself  and  the  com- 
Dlications  due  to  both  conditions  combined  (diminution 
of  the  available  space,  constipation,  vascular  symptoms, 
torsion  of  the  pedicle  of  the  tumor,  retroflexion,  inflamma- 
tions, etc.),  so  that  a  thorough  examination  is  demanded. 

The  diagnosis  is  based  on  the  demonstration  of  preg- 
nancy ;  in  other  words,  the  presence  of  a  gravid  uterus 
and  an  additional  tumor  connected  to  it  only  by  a  pedicle. 
If  the  two  tumors  are  moved  in  opposite  directions  with 
the  hand  the  pedicle  is  stretched  and  may  be  palpated 
through  the  abdomen,  vagina,  or  rectum. 


188      THE  PATHOLOGY  OF  PREGNANCY. 

Among  the  larger  ovarian  tumors  to  be  contiidered  in  this  con- 
nection the  most  frequent  are  multilocular  glandular  myxoid  cysts; 
they  are  rarely  large  enough  to  constitute  an  obstacle  to  labor. 
The  tumors  are  made  up  of  numerous  communicating  cysts  of 
varying  sizes  filled  with  a  mucocolloid  material.  As  they  grow 
from  the  ovary  they  are  connected  with  the  uterus  by  a  pedicle, 
consisting  of  the  ovarian  ligament,  the  vessels,  and  the  tube. 

These  tumors  are  not  in  themselves  malignant,  but  they  may 
be  accompanied  by  firm  papillary  proliferations  which  may  take 
on  a  carcinomatous  character  by  a  typical  proliferating  metastasis. 
The  cysts  themselves  are  dangerous  on  account  of  their  unlimited 
growth,  of  their  exhausting  eff'ect  on  the  entire  body,  and  of  the 
liability  of  the  pedicle  to  become  twisted,  thus  cutting  off  the 
blood-supply  and  leading  to  necrosis. 

Dermoid  cysts  are  recognized  by  the  characteristic  feel  of  their 
sebaceous  contents,  which  are  mixed  with  bones ;  they  may  also 
degenerate  into  carcinomata.  It  is  evident,  therefore,  that  these 
tumors  all  require  speedy  removal. 

In  the  differential  diagnosis  the  first  possibility  to 
be  thought  of  is  extra-uterine  pregnancy  and  its  frequent 
sequel,  retro-uterine  hematocele,  which,  after  the  tubal 
sac  has  ruptured,  discharges  its  contents  into  Douglas' 
pouch,  and  there  forms  a  tense  elastic  tumor  behind  the 
uterus  and  in  apposition  with  the  posterior  vaginal  vault. 
The  tumor  of  a  dilated  bladder  in  retroflexion  and  in- 
carceration of  the  uterus,  subserous  polypoid  myomata, 
uterus  bicornis,  movable  spleen  and  floating  kidney, 
splenic  tumor  and  hydronephrosis,  echinococcic  and  bilat- 
eral ovarian  tumors  are  also  to  be  mentioned  as  possible 
sources  of  error  in  diagnosis. 

Treatment — As  ovarian  tumors  per  se  demand  re- 
moval much  more  than  uterine  myomata,  and  as  their 
presence  during  gestation  may  give  rise  to  complications 
which  it  is  impossible  to  foresee  (23  per  cent,  maternal, 
39  per  cent,  fetal  mortality),  their  extirpation  during 
pregnancy  is  indicated  in  every  case  and  in  every  month, 
although  preferably  in  the  beginning,  irrespective  of  the 
existence  or  absence  of  complications.  Even  double 
ovariotomy  rarely  brings  on  an  abortion.  Operation  is 
contra-indicated  only  w^hen  the  child  has  reached  the 
stage  of  viability  (the  thirty-fourth  week),  and  no  further 


TUMORS.  189 

complications  are  expected  to  arise  from  the  tumor, 
especially  when  the  parents  are  very  desirous  that  the 
child  should  be  preserved  alive.  The  operation  should 
not  be  attempted  if  the  tumor  is  situated  between  the 
layers  of  the  broad  ligament,  because  the  danger  of 
hemorrhage  is  increased  by  the  existence  of  pregnancy 
and  the  operation  would  be  more  dangerous  than  labor 
itself.  In  the  case  of  small  tumors  within  the  true 
pelvis  an  attempt  at  reposition  should  be  made,  avoiding 
any  rough  manipulations  on  account  of  the  danger  of 
tearing  the  walls  of  the  tumor. 

Puncture  is  inadmissible  on  account  of  the  danger  of 
infection. 

Induction  of  abortion  or  premature  labor  is  adapted 
only  to  exceptional  cases  ;  thus,  in  tumors  in  which  reposi- 
tion is  impossible  on  account  of  adhesions  in  all  directions 
within  Douglas'  pouch,  or  on  account  of  their  intraliga- 
mentary  situation,  or  which  are  of  such  a  fibrous  con- 
sistency that  flattening  is  impossible. 

(c)  Cancerous  Growths  of  the  Cervix  and  of  the  Vaginal 
Vault. — Cancer  of  the  uterus  is  not  a  very  rare  complica- 
tion of  pregnancy,  and  when  it  is  present  bodes  very  ill 
for  both  mother  and  child.  The  tumor  itself  grows  very 
rapidly.     The  consequences  are  twofold. 

Either  the  tumor,  which  is  still  rigid,  altogether  pre- 
vents the  expulsion  of  the  ovum  in  premature  labor,  or 
delays  its  escape  so  long  that  ulcerations  are  produced, 
which  sometimes  perforate  into  the  bladder,  and  it  be- 
comes necessary  to  remove  the  fetus  piecemeal  ;  the  rigid 
tissues  may  prevent  tlie  veins  from  contracting  and  thus 
give  rise  to  air-emboli  at  the  site  of  the  ulcerations,  or 
else  the  tissue  alteration  gives  rise  to  hemorrhages  and 
separation  of  the  friable  cancerous  tissue.  Carcinomata 
situated  high  up  in  the  cervix  lead  to  abortion,  or,  by 
secondary  disease,  to  changes  in  the  placental  or  fetal 
tissues  and  premature  expulsion  of  the  ovum.  In  addi- 
tion, the  force  of  the  labor-pains  is  diminished  and  there 
is  a  greater   danger   of   hemorrhage  on   account  of  the 


190      THE  PATHOLOGY  OF  PREGNANCY. 

changes  in  the  tissues  of  the  utems,  or  ulcerations  are 
produced  in  the  softened  lacerated  portions,  especially  in 
the  cervix  (Fig.  110)  and  in  the  vaginal  vault.  Finally, 
there  is  danger  of  septic  endometritis  and  nietrophlebo- 
thrombosis. 

Breech  presentations  are  more  apt  to  be  produced  in 
premature  labors. 

The  diagnosis  from  the  decomposing  remains  of  de- 
cidual tissue  after  an  abortion,  and  from  decomposing 
myomata  and  condylomata  of  the  vaginal  vault,  is  based 
on  the  demonstration  of  cancerous  tissue  and  the  charac- 
teristic nests  in  the  portions  removed  for  examination. 

The  treatment  should  be  directed  solely  to  the  relief 
of  the  mother  from  her  disease ;  hence,  the  possible  methods 
of  procedure  are  : 

(1)  In  the  first  half  of  pregnancy  (Olshausen)  imme- 
diate total  extirpation  of  the  entire  uterus  through  the 
vagina, 

(2)  Later,  as  long  as  the  fetus  is  not  viable,  evacuation 
of  the  amniotic  fluid  and  removal  of  the  ovum,  if  neces- 
sary, by  opening  the  anterior  wall  of  the  uterus  and 
particularly  of  the  cervix  (Pfannenstiel  and  Reckman), 
followed  immediately  by  total  extirpation. 

(3)  After  the  thirty-second  week  :  Cesarean  section  if 
the  cervical  canal  cannot  be  sufficiently  dilated  by  deep 
incisions  (one  long  incision  through  the  anterior  wall, 
otherwise  delivery  per  vias  naturales  and  vaginal  extirpa- 
tion);  this  to  be  followed  by  supravaginal  amputation  and 
subsequent  removal  of  the  cervix  through  the  vagina. 

(4)  In  inoperable  cases  the  life  of  the  mother  is  to  be 
preserved  as  long  as  possible  in  order  to  save  the  life  of 
the  child.  Proliferation  and  ulceration  are  to  be  checked 
by  means  of  the  thermocautery  and  injections  of  arsenic 
and  alcohol.     These  measures  seldom  produce  abortion. 

If  premature  labor  occurs  in  an  inoperable  case,  Porro's 
supravaginal  amputation  of  the  body  of  the  uterus  is  to 
be  performed,  the  stump  being  left  outside  the  peritoneal 
cavity  to  prevent  decomposition. 


ECTOPIC  GESTATION.  191 

?  17.  ECTOPIC  GESTATION.— PLACENTA  PR/EVIA. 
(A)  ECTOPIC  GESTATION. 

(a)  Tubal  Pregnancy. — In  by  far  the  greater  number  of 
ectopic  gestations  the  ovum  develops  ^vithin  the  tube, 
usually  in  its  middle  and  in  the  dilated  portion  or  ampulla. 
From  the  middle  portion  the  fetal  sac  may  push  its  way 
in  between  the  layers  of  the  broad  ligament  and  form  an 
intraligamentary  pregnancy.  An  intraligamentary  gesta- 
tion due  to  rupture  of  the  sac  is  known  as  grossesse  sous- 
periton  eopelvien  ne. 

An  impregnated  ovum  often  lodges  in  a  tubo-ovarian 
cyst  or  in  diverticula  of  the  tubes.  If  the  egg  becomes 
arrested  at  the  fimbriated  extremity  a  tubo-abdominal 
pregnancy  usually  results. 

In  all  these  cases  the  fetal  sac  can  be  diagnosed  as  a 
pedunculated  tumor  (Fig.  112). 

If  the  ovum  lodges  in  the  isthmus  of  the  tube  an  inter- 
stitial tubo-uterine  gestation  is  produced  (Fig.  117).  It 
is  distinguished  anatomically  from  the  above-mentioned 
tubal  pregnancies  by  the  fact  that  the  round  ligament  lies 
to  one  side  and  the  gestation-sac  pushes  its  way  into  the 
uterus.  Both  tubal  orifices  are  occluded  in  these  cases. 
As  the  isthmus  is  very  unyielding  these  gestation-sacs 
rupture  in  almost  every  instance  ;  rarely  the  ovum  may  be 
expelled  into  the  cavity  of  the  uterus. 

In  a  tubal  pregnancy  the  gestation-sac  is  composed  of  perito- 
neum, the  muscular  layer  of  the  tube,  tubal  decidua  vera  and 
circumflexa— which  latter,  if  present  at  all,  only  partially  encircles 
the  ovum — the  fetal  chorion,  and  amnion. 

The  decidua  vera  is  formed  from  the  stroma  of  the  tubal  mucosa ; 
the  cylindrical  epithelium  is  cast  off,  there  is  a  proliferation  of 
large  cells  and  the  papillae  of  the  stroma  are  converted  into  decidua 
consisting  of  a  newly  formed  reticular  layer  of  tissue  into  which 
the  chorionic  villi  penetrate.  The  intervillous  circulation  of 
maternal  blood  is  occasionally  established  by  the  second  month, 
but  there  is  never  a  very  intimate  interlacement  of  fetal  villi  with 
the  vascular  prominences  of  the  decidua  in  the  serotinal  zone. 
The  danger  of  rupture  arises  from  the  fact  that  the  muscular  layer 
does  not  hypertrophy.     In  interstitial  tubo-uterine  pregnancy  the 


192      THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  111.  Gestation  in  the  Rudimentary  Horn  of  a  Uterus  Unicornis 

(after  total  extii'patiou,  by  Kelly,  of  Baltimore). — As  the  rudimentary 
horn  is  shut  off  from  the  uterine  cavitj'-  and  the  corpus  luteum  is  found 
in  the  ovary  of  the  opposite  side,  it  is  evident  that  intraperitoneal  trans- 
migration of  the  ovum  has  taken  place. 


decidua  is  very  thin,  so  that  the  villi  dip  into  the  muscle-bundles 
and  penetrate  into  the  venous  capillaries. 

The  uterine  mucosa  also  becomes  converted  into  a 
decidua  by  the  proliferation  of  large  cells,  the  process 
being  accompanied  by  a  simultaneous  increase  of  the 
entire  organ  both  in  length  and  in  breadth.  This  uterine 
decidua  is  usually  expelled  between  the  second  and  fourth 
months  with  profuse  hemorrhages,  the  muscular  layer  of 
the  uterus  also  becoming  hypertrophied  (Figs.  15,  67,  a 
and  b). 

The  superficial  layer  is  not  covered  with  epithelium  ;  the  lumen 
of  the  glands,  which  are  also  deprived  of  epithelium,  is  narrowed 
down  to  a  minimum  while  the  capillaries  are  much  dilated.  In 
the  deeper  layers  the  gland-ducts  are  covered  with  several  layers 
of  epithelium. 

The  diagnosis  in  most  cases  is  exceedingly  difficult, 
especially  during  the  first  months. 

The  expulsion  of  decidua  which  we  have  just  mentioned 
is  an  important  sign  and  justifies  the  introduction  of  a 
sound  into  the  uterine  cavity,  which,  as  has  been  explained, 
will  be  found  enlarged  in  every  direction  and  empty.  The 
surface  which  was  in  contact  with  the  uterine  wall  shows 
the  openings  of  the  glands  between  irregular  fissures, 
while  on  the  other  side,  looking  toward  the  cavity  of  the 
uterus,  the  openings  are  found  in  a  closer  mesh  work, 
resembling  latticework  (Fig.  67,  a  and  h). 

By  a  careful  combined  examination  the  presence  of  a 
tumor  distinct  from  the  uterus  is  made  out,  and  if  the 
gestation-sac  is  situated  in  the  free  tubal  extremity  the 
tumor  will  be  pedunculated.  If  the  tumor  is  soft  and 
elastic,  the  child  in  all  probability  is  still  alive ;  if,  on  the 
other  hand,  hard  nodular  areas  can  be  felt,  the  fetus  is 
dead,  and  it  is  possible  to  palpate  the  extravasation  which 


ECTOPIC  GESTATION.  193 

takes  place  into  the  fetal  membranes  and  is  accompanied 
by  a  diminution  of  the  amniotic  fluid. 

If  the  idea  of  pregnancy  has  been  entertained  to  begin 
with,  the  examiner  is  struck  by  the  unexpectedly  early 
rising  of  the  gravid  portions  above  the  symphysis,  and 
on  auscultation  the  diagnosis  may  be  confirmed  by  hear- 
ing the  fetal  heart-sounds  in  that  area.  The  subjective 
symptoms  are  much  intensified  and  the  fetal  movements 
in  the  fifth  month  occasion  the  woman  great  pain. 

From  the  fourth  to  the  fifth  months  various  portions  of 
the  fetus  can  be  distinctly  palpated. 

A  normal  nterine  pregnancy  may  be  complicated  with 
extra-uterine  gestation  ;  extra-uterine  pregnancy  on  both 
sides  and  extra-uterine  twin  pregnancy  have  even  been 
observed.  The  diagnosis  of  rupture  of  the  gestation-sac 
is  based  on  all  the  symptoms  of  internal  hemorrhage  with 
violent  shock  and  collapse.  After  the  third  month  rup- 
ture is  especially  to  be  dreaded  on  account  of  death  from 
internal  hemorrhcige.  The  retro-uterine  hematocele  is 
felt  like  a  tense  tumor  behind  and  by  the  side  of  the 
uterus.  In  some  cases  rupture  takes  place  without  a 
marked  liemorrhage,  and  the  gradually  escaping  ovum 
has  time  to  attach  itself  by  one  pole  to  the  serosa  and 
establish  a  new  blood-supply. 

Differential  Diagnosis. — The  menstrual  history  aids 
in  the  differentiation  from  ovarian  cysts,  subserous 
fibroma,  and  pelvic  abscess  (fever) ;  retroflexion  of  a 
gravid  uterus  (§  15)  is  always  attended  Avith  marked 
ischuria,  which  is  absent  in  ectopic  pregnancies,  not  to 
mention  ru])ture  of  the  amniotic  sac  and  the  anterior  dis- 
placement of  the  portio  vaginalis  and  thinning  of  the 
anterior  lip  of  the  os,  which  we  observe  in  the  former 
condition. 

Among  the  anatomical  causes  of  tubal  pregnancy,  the 
most  important  is  gonorrheal  alteration  of  the  cylindrical 
epithelium. 

The  cells  become  swollen  and  lose  their  cilia.  In  addition,  the 
inflammatory  proliferation  of  the  papillary  stroma  gives  rise  to  an 

13 


194  THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  112.  Tubal  Pregnancy  on  tlie  Right  Side ;  Left  Lateral  Displace- 
ment of  the  Uterus  ;  Corpus  Luteum  Verum  on  the  Left  Side. — Trans- 
migration of  the  ovum. 

Fig.  113.  Ruptured  Tubal  Gestation-sac ;  child  in  Douglas'  cul-de- 
sac;  adhesive  peritonitis  leading  to  kinking  of  the  right  tube.  Eight 
lateral  displacement  of  the  uterus  (original  drawing  from  a  specimen  in 
the  Munich  Gynecological  Clinic). 


interlacing  mass  of  excrescences,  the  minute  cleft-like  interstices 
of  which  are  filled  with  secretion  and  partially  desquamated  epi- 
thelium. The  connective-tissue  growth  which  accompanies  the 
deeper  interstitial  inflammation  destroys  the  contractility  of  the 
muscularis  and  thus  the  further  progress  of  the  ovum  is  arrested. 

Coarse  primary  alterations  may  be  causative  in  pre- 
venting the  passage  of  the  ovum,  as,  for  instance,  when 
the  Fallopian  tube  is  constricted  or  acutely  flexed  by  ad- 
hesions in  localized  peritonitis ;  another  cause  is  found  in 
the  congenital  malformations  sometimes  occurring  in  the 
tube  in  the  form  of  marked  convolutions  (Freund). 

The  same  effect  may  be  produced  by  tuberculosis  with 
cheesy  degeneration  as  by  severe  gonorrheal  salpingitis. 
Uterine  polypi  blocking  the  orifice  of  the  tubes,  or  similar 
tumors  and  small  myomata  in  the  tube  itself  (salpingitis 
nodosa  of  the  uterine  portion  of  the  tube),  may  prevent 
the  entrance  of  the  ovum  into  the  uterine  cavity.  Emo- 
tional disturbances,  even  within  the  sphere  of  sexual  life, 
and  extra-uterine  transmigration  of  the  ovum  may,  in 
addition,  prevent  the  impregnated  ovum  from  following 
its  normal  path  (Figs.  Ill  and  112).  In  such  cases  the 
condition  is  usually  preceded  by  total  or  at  least  long- 
protracted  sterility. 

The  results  of  ectopic  gestation  are  as  follows  : 

1.  Pregnancy  may  go  on  to  term  and  the  fetus  die 
unless  it  is  delivered  by  means  of  a  celiosalpingotomy. 

2.  Labor-pains  come  on  and  the  ovum  is  expelled  (born) 
into  the  abdominal  cavity  through  the  fimbriated  ex- 
tremity (tubal  abortion,  Fig.  116). 

3.  Rupture  of  the  gestation-sac  either  into  the  abdom- 
inal cavity  (Fig.  113)  or  between  the  layers  of  the  broad 
ligament. 


Tab.  53. 


Fig.  112. 


Fig.  113. 


ECTOPIC  GESTATION.  195 

4.  Tlie  cliikl  may  be  expelled  into  the  uterine  eavity  and 
born  in  the  natural  way  (in  interstitial  pregnancy,  Fig.  117j. 

0.  Death  of  the  fetus  on  account  of  placental  disease  : 
extravasations  beneath  the  chorion,  myoma,  hydramnios. 
The  same  conditions  may  produce  monstrosities. 

When  rupture  takes  place  the  woman  goes  into  sudden 
collapse  as  the  result  of  shock  and  hemorrhage.  The 
child  usually  dies  at  once.  The  mother  then  has  a  chill 
and  the  milk  begins  to  trickle  from  the  enlarged  mammary 
glands.  If  rupture  takes  place  early,  a  retro-uterine  he- 
matocele remains  (see  Atlas  of  Gt/necoiof/j/) ;  the  placenta 
mav  be  entirely  absorbed,  and  the  hematocele  may  later 
undergo  suppuration  or  decomposition. 

In  very  rare  cases  the  child  may  continue  to  grow- 
within  the  abdominal  cavity  without  any  gestation-sac. 
Such  cases,  known  as  tubal  abortions,  lead  to  secondary 
abdominal  pregnancy  (Fig.  113). 

(6)  Abdominal  Pregnancy. — The  course  is  the  same  in 
the  primary  as  in  the  secondary  form,  to  which  we  have 
refei'red  in  the  foregoing  paragraph.  The  possibility  of 
a  primary  abdominal  pregnancy  taking  place  is  incon- 
trovertibly  proven  by  Schlechtendahl's  case,  in  which  the 
gestation-sac  became  encysted  in  the  region  of  the  spleen  ; 
although  many  cases  diagnosed  anatomically  as  abdominal 
jiregnancy  prove  to  be  primarily  derived  from  the  epithe- 
lium of  the  fimbriae  or  to  be  nothing  more  or  less  than 
tubal  gestation-sacs. 

The  decidua  is  formed  from  the  peritoneum,  usually  from  the 
])osterior  surface  of  the  uterus,  and  fibrinous  bands  re-enforce  the 
walls  of  the  gestation-sac.  which  may  attain  a  thickness  of  from 
f  to  f  in.  (1  to  1^  cm.).  ^Muscle-fibers  derived  from  the  subserous 
tissue  contribute  the  muscular  element.  Fibers  with  transverse 
striations  have  even  been  found,  and  I  may  remark  in  this  con- 
nection that  such  fibers  have  often  been  found  at  the  placental 
site  in  the  uterus  in  an  ordinary  uterine  gestation.  In  all  ectopic 
gestations  the  thickness  of  the  w^alls,  and,  therefore,  the  possi- 
bility of  rupture,  depends  on  the  state  of  the  muscularis.  Fre- 
quently there  is  an  entire  absence  of  maternal  tissue  in  a  consider- 
able portion  of  the  periphery  of  the  ovum  ;  occasionally  a  decidua 
reflexa  appears  to  be  formed. 


196  THE  PATHOLOGY  OF  PREGNANCY. 

Fig.  114.  Perforation  of  a  Tubal  Sac  into  the  Bladder  and  Rectum 
by  Fetal  Bones,  the  fetus  haviug  undergone  absorption.  Anteversion 
of  the  uterus. 

Fig.  115.  Ovarian  Pregnancy. — Adhesive  peritonitis ;  kinking  of  left 
tube. 

Fig.  116.  Abdominal  Pregnancy. — Adhesive  peritonitis. 

Fig.  117.  Interstitial  Extra-uterine  Pregnancy. 

Figs.  114-117.  Original  drawings,  after  specimens  from  the  Munich 
Gynecological  Clinic. 

As  regards  the  diagnosis  I  can  only  refer  to  that  of  a 
tubal  pregnancy. 

Course. — Abdominal  gestation  may  end  in  various 
ways : 

1.  The  child  lives  to  term  and  labor-pains  make  their 
appearance. 

2.  Premature  labor-pains,  separation  of  the  placenta, 
hemorrhage  into  the  placenta,  death  of  the  fetus. 

3.  After  death  the  fetus  undergoes  the  same  changes 
in  this  variety  as  it  does  in  tubal  and  ovarian  pregnancies. 
These  changes  are  as  follows  : 

(a)  Absorption,  the  rapidity  depending  on  the  number 
of  septic  micro-organisms  present.  The  amniotic  fluid 
and  the  tissue-juices  are  absorbed,  the  fetus  and  fetal 
membranes  coalesce,  the  mass  becomes  organized  by  the 
proliferation  of  granulation-tissue  as  far  as  the  bones,  or 
septic  peritonitis  results. 

(6)  Expulsion,  with  or  without  absorption,  by  ulcera- 
tion through  the  bladder,  the  rectum  (Fig.  115),  the 
vagina,  or  the  anterior  abdominal  wall,  the  ulceration 
resulting  from  the  action  of  micro-organisms  within  the 

tubes. 

(c)  Calcification  beginning  in  the  peritoneal  bands  (usu- 
ally in  the  absence  of  septic  micro-organisms).  It  may 
be  of  various  kinds  : 

(«)  Lithokelyphos,  or  calcification  of  the  membranes, 
the  child  being"^  completely  preserved  within  this  calcified 
envelope.^ 

1  As,  for  instance,  in  the  cases  of  Virchow  and  Kiichenmeister,  and  the 
London  and  Langensalza  "  petrified  infants." 


Tnh.  r,.',. 


Fig.  114. 


Fig.  115. 


Tiih.  55. 


Fig.  116. 


Fig.  117. 


ECTOPIC  GESTATION.  197 

ifi)  CalcificatioD  of  the  coutiguous  surface  of  the  fetus 
— lithokelyphop?edion/ 

(y)  Iniprcgnatiou  of  the  fetus  with  lime-salts  with 
entire  absence  of  the  fetal  membranes — lithop^dion  ;  tlie 
internal  organs  are  only  partially  involved  in  the  cal- 
cification ;  they  undergo  a  fatty  change  and  are  converted 
into  lime-soap,  resembling  ambergris.^ 

((/)  The  fetus  remains  as  a  skeleton. 

(c)  Ovarian  Pregnancy. — This  is  the  rarest  form  of  all. 
Impregnation  takes  place  : 

(1)  In  the  follicle,  because  the  rupture  is  too  small  for 
the  escape  of  the  ovum. 

The  chorion  dips  into  the  surrounding  stroma,  the 
decidua  is  contributed  by  the  zona  granulosa  of  the 
Graafian  follicle,  assisted  by  the  ovarian  stroma.  The 
stalk  of  the  tumor  is  formed  by  the  ovarian  ligament. 

(2)  The  ovum  becomes  impregnated  primarily  in  the 
follicle  and  the  gestation-sac,  embedded  in  masses  of  fib- 
rin, projects  into  the  abdomen  forming  an  ovario-abdominal 
gestation. 

(3)  Tubo-ovarian  pregnancy  results  if  a  congenital  or 
acquired  ovarian  tube  is  present  (from  perisal])ingitis  and 
kinking  of  the  tube,  cf.  §  1). 

(4)  The  ovum  is  inij^regnated  in  a  tubo-ovarian  cyst. 
A  small  cyst  from  a  partially  degenerated  ovary  ruptures 
into  a  tube  and  hydrosalpinx  results. 

Ovarian  gestation  has  been  observed  once  or  twice  in 
an  inguinal  hernia  containing  an  ovary.  The  fetus  rarely 
attains  maturity  in  this  form  of  ectopic  gestation. 

Treatment  of  Ectopic  Gestation. — The  most 
favorable  termination  is  premature  rupture  of  the  gesta- 
tion-sac in  the  first  two  months,  followed  by  absorption 
of  the  fetus,  or  early  mummification  and  petrifaction  if 
the  fetus  is  too  large  to  be  absorbed  ;  but  even  under  these 
conditions  25  per  cent,  of  the  cases  terminate  fatally. 
After  the  second  month  the  mother's  life  is  threatened  by 

*  For  instance,  the  petrified  infants  at  Leinzell  and  Pont-a-Mousson. 
2  The  petrified  infants  at  Heidelberg,  Liibben,  and  Toulouse. 


198      THE  PATHOLOGY  OF  PREGNANCY. 

hemorrhages,  and  the  fetus,  on  account  of  its  greater  size, 
is  more  apt  to  undergo  decomposition. 

The  question  of  treatment  is  still  a  very  difficult  one  to 
decide.  The  ideal  procedure — inaction  until  the  child 
has  come  to  maturity  and  preservation  of  both  mother  and 
child — is  a  very  risky  undertaking  in  view  of  what  has 
been  said  above  and  of  our  modern  methods  of  operation. 
The  indications  are  about  as  follows  : 

(1)  During  the  first  three  months  injection  of  gr.  ss 
(0.03  gm.)  of  morphin,  once  repeated,  into  the  amniotic 
sac  may  be  tried  under  certain  conditions,  without  aspirat- 
ing the  amniotic  fluid  and  under  strict  antiseptic  precau- 
tions, with  a  view  of  bringing  about  the  death  of  the  fetus 
(v.  Winckel). 

(2)  If  the  fetus  continues  to  grow  in  spite  of  this,  or 
if  the  subjective  symptoms  become  violent  or  alarming — 
and  this  applies  especially  to  obscure  cases — an  abdominal 
section  should  be  made.  Opening  of  the  vaginal  vault  and 
pouch  of  Douglas  is  permissible  only  when  the  tumor  is 
small,  distinctly  pedunculated,  and  non-adherent. 

(3)  In  advanced  ectopic  gestations  the  fetus  may  be 
allowed  to  go  on  to  viability  only  in  case  the  marriage  has 
been  sterile  and  a  living  child  is  earnestly  desired.  The 
mother  should  then  be  confined  to  bed.  Otherwise  im- 
mediate celiotomy  is  indicated  ;  or, 

(4)  If  the  fetus  is  dead,  it  should  be  removed  some  time 
later  (preferably  six  months)  by  means  of  a  celiotomy. 

(5)  If  rupture  has  taken  place,  celiotomy  may  be  per- 
formed if  the  woman  is  not  in  too  profound  a  condition 
of  collapse  and  rupture  has  occurred  only  a  few  hours 
previously ;  if  the  symptoms  of  hemorrhage  are  too 
severe  or  the  shock  is  too  profound,  the  patient  must  not 
be  deprived  of  the  extravasated  blood.  The  treatment 
then  consists  of  absolute  rest,  opiates,  antispasmodics,  the 
application  of  a  sand-bag  to  the  abdomen,  elevation  of 
the  pelvis,  and  subcutaneous,  rectal,  and  intravenous  in- 
jections of  decinormal  salt  solution  ;  the  fetus  being  re- 
moved later. 


PLACENTA  PREVIA.  199 

If  the  accident  has  occurred  some  time  previously,  and 
there  is  no  immediate  danger,  an  expectant  policy  may  be 
adopted. 

((i)  If,  during  the  later  months,  the  gestation-sac  can- 
not be  removed,  it  is  to  be  fixed  extraperitoneally  into  the 
abdominal  wound  and  tamponed. 

(7)  In  suppuration  of  the  hematocele  incision  through 
the  vagina  and  drainage  are  indicated. 

(B)  PLACENTA   PREVIA. 

If  the  attachment  of  the  ovum  to  the  uterine  wall  is 
abnormal,  so  that  the  decidua  serotina  is  inserted  in  the 
lower  uterine  segment  from  the  very  beginning  of  preg- 
nancy (with  the  exception  of  a  few  cases  in  which  the 
decidua  reflexa,  which  is  usually  devoid  of  glands  and 
vessels,  is  traversed  by  loops  of  blood-vessels),  the  condi- 
tion kno\vn  as  placenta  prsevia  results.  As  a  result  of  the 
uterine  contractions,  the  lower  uterine  segment  undergoes 
marked  passive  distention  even  during  pregnancy,  but 
particularly  during  labor.  The  traction  thus  exerted 
tends  to  loosen  the  placenta,  which  then  either  blocks  the 
entire  internal  os  in  the  form  of  placenta  prsevia  centralis 
(Fig.  13  in  the  text),  or  the  edge  projects  over  the  orifice, 
when  the  condition  is  know^n  as  placenta  prsevia  mar- 
ginalis  (Plate  23,  and  Fig.  14  in  the  text).  Depending 
on  the  variety  of  placenta  previa  present  we  have,  after 
the  seventh  month  in  placenta  prsevia  centralis,  after  the 
eighth  month  in  placenta  prsevia  lateralis,  after  the 
ninth  month  in  placenta  prsevia  marginalis,  as  an  im- 
portant diagnostic  sign,  hemorrhage  due  to  injury  of  the 
placental  vessels,  and,  rarely,  of  the  fetal  vessels  within 
the  chorionic  villi  or  even  to  laceration  of  the  placenta. 
If  this  accident  occurs  during  pregnancy,  a  placenta 
pr^evia  centralis  is  converted  into  a  placenta  prsevia  siic- 
centuriata  (Fig.  13  in  the  text)  ;  if,  on  the  other  hand, 
one  lobe  of  the  placenta  is  torn  away  during  labor,  the 
placenta  previa  centralis  is  converted  into  a  placenta 
pr^evia  lateralis. 


200 


THE  PATHOLOGY  OF  PREGNANCY. 


The  hemorrhages  Avhich  not  infrequently  occur  in  the 
first  half  of  pregnancy  are  explained  partly  by  the  uterine 
contractions,  partly  by  the  loosening  of  the  villi  from  the 
attenuated  lower  uterine  segment,  particularly  when  the 
placenta  is  much  flattened. 

The  abnormal  insertion  of  the  placenta  takes  place  at 
the  very  beginning  of  gestation.  Thus,  Hunter  and 
Gottschalk  have  found  ova  inserted  at  the  internal  os  as 
early  as  the  first  month. 

(a)  The  uterine  cavity  may  not  be  adapted  to  the  re- 
ception of  the  ovum.     This  is  the  case  in  fibromyoma ; 


Fig.  13. — Placental  infarct. 


Fig.  14. — Placenta  prsevia. 


in  malformations  and  malpositions  of  tlie  uterus  (uterus 
unicornis,  bicornis,  or  deep  insertion  of  the  oviducts)  ;  in 
defective  involution  and  consequent  dilatation  of  the 
cavity,  as  when  the  woman  is  allowed  to  get  up  too  soon  ; 
in  relaxation  of  the  uterine  wall  due  to  several  rapidlv 
succeeding  pregnancies,  a  condition  to  which  older  women 
in  their  second  or  third  pregnancies  are  particularly 
liable;  or  in  cases  of  abnormally  wide  uterine  cavities 
due  to  chronic  catarrh  (metritis) — in  all  of  which  condi- 
tions there  is  an  incomplete  decidua  formation  owing  to 
disease  of  the  mucous  membrane. 


PLACENTA  PREVIA.  201 

(6)  The  condition  of  the  lower  uterine  segment  itself 
may  be  such  as  to  favor  a  low  insertion  near  the  internal 
OS.  This  occurs  in  cancer  of  the  cervix,  because,  as  in 
endometritis,  the  decidua  reflexa  is  prevented  by  the  can- 
cerous secretion  from  undergoing  liquefiction  ;  there  is  a 
marked  increase  in  the  vascular  supply,  especially  in  the 
fold  of  the  reflected  portion,  causing   the  chorionic  villi 


Fig.  15. — Velamentous  insertion  of  tlie  placenta. 

topersist  in  that  region.  It  occurs  also  in  old  lacerations 
of  the  cervix. 

(c)  Lastly,  when  the  decidua  serotina  covers  an  ab- 
normally large  area  ;  hence,  the  condition  is  especially 
liable  to  occur  in  twin  pregnancies. 

We  must  also  emphasize  the  frequent  occurrence  of 
velamentous  insertion  (Fig.  15  in  the  text),  placenta  suc- 
centuriafa,  marginata,  membranacea,  and  of  placental 
infarcts  (Fig.  13  in  the  text),  in  combination  with  placenta 
praevia  (Figs.  96  and  101). 

It  is  evident,  therefore,  that  disease  of  the  endometrium 
and  its  inability  to  nourish  the  ovum  are  the  most  im- 


202      THE  PATHOLOGY  OF  PREGNANCY. 

portant  factors  in  the  etiology.  Ahlfeld  observed  in  cer- 
tain puerperal  uteri  the  absence  of  a  soft,  smooth  mucous 
membrane  and  of  a  true  placental  site,  that  is,  the 
thrombosis  was  less  marked. 

These  anatomical  findings  explain  why  multiparse  and 
elderly  primiparse  and  women  of  the  poorer  classes,  with 
whom  the  element  of  hard  work  enters  into  the  question, 
are  particularly  liable  to  placenta  prsevia,  and  often  suffer 
from  the  condition  repeatedly. 

The  diagnosis  rests  chiefly  on  the  occurrence  of  inter- 
mittent hemorrhages  during  pregnancy.  The  anatomical 
findings  are  only  occasionally  of  value.  It  may  be  possi- 
ble to  palpate  the  low  insertion  of  the  placenta  through 
the  abdominal  walls,  or  the  soft,  doughy  consistency  of  the 
supravaginal  portion  of  the  cervix  may  be  noticed,  or  it 
may  be  impossible  to  palpate  the  fetal  parts  through  the 
vagina,  etc.  In  the  differential  diagnosis  it  is  to  be 
remembered  that  similar  hemorrhages  occur  in  hydatid 
mole,  in  which  condition,  however,  no  fetal  parts  can  be 
palpated  and  the  size  of  the  uterus  does  not  correspond  to 
the  period  of  pregnancy. 

Course. — In  a  great  number  of  cases  the  ovum  is 
aborted  (Dohrn).  The  internal  os  may  remain  closed  until 
the  time  of  parturition,  so  that  a  lower  uterine  segment 
cannot  be  formed  and  traction  on  the  placenta  is  impossi- 
ble. In  such  a  case  there  are  no  hemorrhages  during 
pregnancy. 

If  the  integrity  of  the  cervix  is  not  preserved  and  the 
supravaginal  portion  protrudes  with  the  internal  os,  hemor- 
rhage occurs  early  and  alterations  take  place  in  the 
placenta.  The  fetus  may  be  asphyxiated  by  the  hemor- 
rhage, or  a  small  lobule  of  the  placenta  is  torn  away  and, 
after  becoming  emptied  of  blood,  undergoes  atrophy. 

During  labor,  especially  if  it  is  premature,  there  is 
great  danger  of  lacerations  in  the  undeveloped  portion  of 
the  cervix,  which  has  a  tendency  to  stricture  formation  ; 
hence,  an  accident  is  particularly  liable  to  occur  during 
operative  interferences. 


PLACENTA  PREVIA.  203 

After  labor-pains  have  made  their  appearance  the 
hemorrhage  is  increased  during  the  pauses  and  the  lower 
portion  of  the  placenta  is  detached  by  the  uterine  con- 
tractions. The  hemorrhage  is  often  increased  by  lacera- 
tions of  the  fetal  vessels  in  marginal  and  velamentous 
insertions,  as  the  resulting  stasis  leads  to  engorgement  and 
separation  of  the  lowest  cotyledons  and  further  hemor- 
rhage. Although  the  labor-pains  momentarily  compress 
the  uterine  vessels  they  are  greatly  diminished  in  strength, 
partly  because  labor  is  premature,  partly  on  account  of 
the  extreme  teuuity  of  the  muscular  layer  in  the  lower 
uterine  segment  and  because  the  most  effective  stimulus — 
the  descent  of  the  amniotic  sac — is  wanting,  partly  also 
because  a  vicious  circle  is  established,  and  the  loss  of 
blood  in  turn  diminishes  the  contracting  power  of  the 
muscularis. 

On  account  of  the  gaping  of  the  vessels  there  is  danger 
of  air  entering  the  circulation.  Again,  the  atony  of  the 
placental  site  leads  to  further  hemorrhages,  which  are 
arrested  in  the  end  only  by  the  reversed  arterial  supply 
of  the  lower  uterine  segment  from  the  upper  thicker 
muscular  layers,  as  was  described  in  §  8. 

As  a  result  of  deviation  of  the  head  in  the  spherical 
lower  portion  of  the  uterus  abnormal  presentations  occur, 
and  occasionally  prolapse  of  the  placenta  takes  place 
before  the  child  is  delivered.  Retention  of  fetal  mem- 
branes is  a  common  accident.  Death  occurs  in  25  per  cent, 
of  all  the  cases,  either  from  hemorrhage  or  from  infection 
due  to  the  necessary  manipulations  when  the  cervix  is 
only  partially  opened  (lacertions  and  secondary  anemia). 

The  treatment  is  principally  directed  to  the  control 
of  the  hemorrhage.  Firm  aseptic  tamponade  of  the  cervix 
and  vagina  with  iodoform  gauze  or  with  Barnes-Fehling's 
violin-shaped  colpeurynter,  the  placenta  pr^evia  centralis 
being  perforated  ;  dilatation  of  the  os  and  version  (after 
Braxton  Hicks — see  the  author's  Atlas  of  Labor  and 
Operative  Obstetrics)  are  always  to  be  performed  when  the 
entire  cervical  canal  admits  two  fingers,  but  without  sub- 


204  DEFORMITIES  OF  THE  PELVIS. 

sequent  extraction,  one  foot  being  brought  down  to  act  as 
a  tampon  ;  or,  without  version,  the  uterus  may  be  tam- 
poned with  iodoform,  nosophen,  or  silver  gauze  until  the 
OS  is  completely  dilated  ;  analeptic  remedies  (antispas- 
modics), ergotin,  and,  if  necessary,  subcutaneous  or  rectal 
injections  of  0.6  per  cent,  salt  solution  may  be  given. 
In  longitudinal  presentations  the  hemorrhage  may  be 
stopped  by  rupturing  the  bag  of  waters.  In  postpartum 
hemorrhage  due  to  atony  resort  may  be  had  to  ergotin, 
bimanual  rubbing  and  kneading  of  the  uterus,  which 
should  be  anteflexed,  either  with  one  finger  in  the  uterine 
cavity  or — if  it  can  be  done  at  once  and  for  the  purpose 
of  combining  massage — from  without,  followed  by  tam- 
ponade of  the  uterine  cavity  after  Diihrssen.  The  most 
effective  measure  is  to  draw  down  the  uterus  in  front  of 
the  vulva  and  seize  the  portio  vaginalis  with  a  pair  of 
stout  Muzeux  forceps.  The  kinking  of  the  uterine  ves- 
sels, which  is  thus  effected,  directly  diminishes  the  hemor- 
rhage and  acts  indirectly  to  produce  contraction  on  account 
of  the  accumulation  of  carbon  dioxide.  Not  infrequently 
the  placenta  has  to  be  removed  with  the  hand  introduced 
into  the  uterus. 


CHAPTEE  YI. 


DEFORMITIES  OF  THE   PELVIS   AND  THEIR   IN= 
FLUENCE  ON    PREGNANCY   AND   LABOR. 

I   i8.    GENERAL   REMARKS  ON    THE   DIAGNOSIS    AND 
TREATMENT  OF  DEFORMED  PELVES. 

For  the  diagnosis  the  reader  is  referred  to  §  3.  The 
effect  of  skeletal  deformities  on  the  pelvis  is  to  be  borne 
in  mind  and  careful  palpation  of  the  pelvic  cavity  must 
never  be  neglected.^ 

1  Kyphosis  in  the  lower  portion  of  the  column  suggests  a  funnel-shaped 
pelvis.  Scoliosis  and  a  limping  gait  point  to  an  oblique  pelvis,  while  the 
characteristic  rachitic  deformity  with  joint  enlargements  and  pendulous 
abdomen  should  arouse  the  suspicion  of  a  flat  pelvis. 


GENERAL  REMARKS  ON  DEFORMED  PELVES.    205 

Both  internal  and  external  asymmetry  can  be  determined 
by  inspection  and  palpation.  In  rachitic  pelves  the  dis- 
tance between  the  spines  is  equal  to,  or  greater  than,  the 
distance  between  the  crests.  In  obliquely  contracted 
pelves  one  iliac  bone  is  often  higher  than  the  other.  In 
equally  contracted  pelves  the  interspinous  distance  is 
equal  to,  or  less  than,  a  span  from  the  thumb  to  the  little 
finger  (8f  in.  =  23  cm.).  Internally  we  determine  the 
configuration  and  width  of  the  linea  terminalis  ;  the  posi- 
tion of  the  promontory,  especially  with  relation  to  the 
superior  strait ;  the  condition  of  the  cartilage  in  the 
symphysis  (cf.  §  20,  Xo.  12)  ;  and  the  inclination  of  the 
symphysis  (more  vertical  in  rachitic  pelves).  We  also 
determine  whether  the  promontory  and  symphysis  are  in 
the  same  sagittal  plane  or  not  (oblique  pelves).  We  first 
palpate  the  tuberosities  and  the  spine  of  the  ischium, 
ascertain  the  width  of  the  pubic  arch  (the  distance  between 
the  former  is  diminished  in  funnel-shaped  pelves,  the 
latter  is  greater  in  rachitic  pelves),  and  examine  the  coc- 
cyx for  a  possible  anterior  luxation.  Exostoses  are  to  be 
sought  for  in  the  sites  of  predilection  mentioned  in  §  20, 
No.  12.  The  history  of  former  labors  is  also  of  great 
importance. 

By  pelvimetry  we  detect  general  contractions  of  the 
perimeter  of  the  pelvis  or  diminution  of  single  diameters : 
the  true  conjugate  of  the  oblique  diameters  or  the  trans- 
verse diameter.  The  measurements  of  the  pelvic  outlet 
are  also  ascertained. 

If  the  diminution  of  the  conjugate  is  due  to  rachitis, 
we  must  subtract  more  than  the  usual  number  of  centi- 
meters from  the  diagonal  conjugate  on  account  of  the  more 
vertical  position  of  the  symphysis  ;  that  is,  instead  of  |-  in. 
(1.5  cm.)  we  subtract  from  -f-  to  1  in.  (2  to  2.5  cm.).  (See 
§§  3  and  4,  the  relations  between  the  external  conjugate 
of  Baudelocque  in  flat  rachitic  pelves  and  the  influence  of 
the  woman's  position  on  pelvic  measurements,  Walcher's 
position ;  also  the  value  of  external  measurements  in  the 


206  DEFORMITIES  OF  THE  PELVIS. 

determination  of  the  size  of  the  superior  strait,  especially 
in  contracted  pelves  ;  cf.  §  3.) 

The  rigidity  of  the  pelvic  joints  and  the  compressibility 
of  the  fetal  skull  during  labor  have  been  referred  to  in  §  7, 
under  "  Configuration  of  the  Skull. '^  A  pelvis  is  con- 
sidered contracted  in  the  obstetrical  sense  not  only  when 
it  constitutes  an  obstacle  to  labor,  but  when  it  leads  to 
abnormal  presentations  ;  Litzmann  assumes  as  a  limit  for 
the  true  conjugate  3 J  to  4  in.  (9.7  to  10  cm.). 

Anomalies  in  shape  and  position  of  the  uterus  and  of 
the  fetus  during  pregnancy  also  interfere  with  the  proper 
entrance  of  the  fetus  into  the  true  pelvis. 

The  duration  of  labor  is  increased  by  half;  in  56  per 
cent,  of  all  the  cases  the  head  does  not  engage  in  the  true 
pelvis  until  the  external  os  is  completely  dilated.  As  a 
result  the  bag  of  waters  frequently  ruptures  prematurely, 
that  is,  before  the  os  is  completely  dilated.  In  flat  pelves 
there  is  a  laro^e  amount  of  amniotic  fluid  in  front  of  the 
head  and  this  permits  prolapse  of  the  cord  or  of  one  of 
the  extremities,  and  leads  to  further  anomalies  in  the 
attitude  and  presentation  of  the  child. 

The  force  of  the  labor-pains  is  not  diminished  a  priori, 
but  they  may  become  weaker  secondarily ;  at  least,  their 
effect  may  be  diminished  because  some  of  the  muscle- 
fibers  go  into  a  state  of  partial  spasm  from  failure  of  the 
head  to  descend  or  subsequent  fixation  of  the  cervix 
between  the  head  and  the  pelvic  wall.  Premature  dis- 
charge of  the  amniotic  fluid — in  which  case  the  dilatation 
of  the  OS  is  accomplished  with  much  more  pain  to  the 
mother  by  the  pressure  of  the  head,  and  edema,  lacerations, 
and  contusions  are  apt  to  result — abnormal  positions  of  the 
child,  and,  finally,  old  scars  in  the  vaginal  vault  may  also 
impair  the  strength  of  the  labor-pains.  The  lower  uterine 
segment  is  very  much  distended,  hence,  pressure-necrosis 
and  rupture  or  perforation  are  very  apt  to  occur. 

The  joints  of  the  pelvis  may  be  torn  apart  either  by 
raising  the  handles  of  the  forceps  too  early,  especially  if 
the  operator  indulges  in  forced  rocking  movements  from 


GENERAL  REMARKS  ON  DEFORMED  PELVES.   207 

side  to  side,  or,  more  rarely,  when  tlie  head  lias  reached 
its  limits  of  compression  and  accommodation  to  the  pelvic 
cavity.  Among  the  predisposing  factors  to  this  accident 
are  primary  inflammations  and  snppurations,  osteomalacia, 
caries,  tumors,  and,  in  funnel-shaped  pelves,  the  leverage 
Avhich  the  descending  rami  of  the  pubis  exert  on  the 
symphysis  during  the  passage  of  the  head. 

The  diagnosis  of  separation  is  made  by  feeling  the 
bones  give  way  and  by  the  presence  of  constant  pain  and 
abnormal  mobility.  The  bones  reunite  with  or  without 
the  application  of  a  binder.  The  latter  consists  of  two 
towels  passing  around  the  region  of  the  sacrum,  crests, 
and  spines,  tied  together  above  the  symphysis  (Ahlfeld). 
Artificial  separation  of  the  symphysis  or  symphysiotomy 
has  lately  come  into  vogue  again  to  prevent  laceration  of 
the  perineum,  and  has  been  attended  with  some  success, 
but  it  should  be  attempted  only  in  hospitals. 

Injuries  to  the  child  consist  in  disturbances  of  the  pla- 
cental circulation,  and,  therefore,  of  the  respiration,  by 
the  powerful  contractions  with  which  the  uterus  attempts 
to  overcome  the  obstacle  presented  by  a  contracted  pelvis. 
In  some  cases  the  uterus  may  go  into  tetanic  contraction. 
As  a  result  of  long-contined  pressure,  especially  if  the 
amniotic  fluid  is  evacuated  early,  we  have  edema,  bruises, 
necroses,  depressions,  and  fissures  and  fractures  of  the 
skull.  The  overlapping  of  the  bones  of  the  skull  may  be 
excessive  (cf.  Figs.  130-1 33a,  and  §  20,  under  No.  3a). 
Such  injuries  lead  to  the  formation  of  cephalhematomata 
or  of  subdural  extravasations.  Fracture  may  also  occur 
at  the  base  of  the  skull  or  in  one  of  the  cervical  vertebrae. 
The  size  of  the  fetal  head  and  body  must  be  determined 
by  bimanual  examination  (see  §  2),  remembering  that  in  a 
multipara  the  resistance  offered  by  the  maternal  soft  parts 
and  the  size  of  the  head  are  greater  than  in  primiparse. 
An  important  procedure,  both  from  a  diagnostic  and  from 
a  therapeutic  point  of  view,  is  to  exert  moderate  pressure 
on  the  head  once  a  week  for  from  one  to  one  and  one- 
half  minutes,  if  possible  as  early  as  the  twenty-eighth  to 


208  DEFORMITIES  OF  THE  PELVIS. 

the  thirtieth  Aveek,  so  as  to  force  it  to  enter  the  superior 
strait. 

In  the  matter  of  treatment  it  is  to  be  remembered 
that : 

(1)  According  to  v.  AVinckel,  seven-tenths  of  all  labors 
in  contracted  pelves  are  terminated  without  operative 
interference ;  and, 

(2)  That  the  most  scrupulous  asepsis  is  to  be  observed 
from  the  very  first  examination,  even  if  the  accoucheur  is 
convinced  beforehand  that  an  operation  will  probably  be 
necessary.  The  fissures  and  excoriations  which  are  always 
produced  are  very  liable  to  become  converted  into  ulcer- 
ating surfaces  covered  with  the  semifluid,  greenish  exudate 
characteristic  of  septic  invasion.  The  expectant  treatment 
consists  in  carefully  controlling  the  advance  of  the  head 
and  the  strength  of  the  labor-pains,  that  is,  a  primipara 
should  be  forbidden  to  bear  down  at  all,  and  in  every  case 
abdominal  pressure  should  be  forbidden  until  the  head  has 
passed' the  superior  strait.  The  labor-pains  may  be  regu- 
lated by  the  application  of  hot  compresses,  baths,  mustard- 
plasters,  and  the  administration  of  morphin,  chloral 
hydrate,  and  chloroform.  The  woman  should  lie  on  the 
side  on  which  the  presenting  part  is  felt.  If  the  abdomen 
is  pendulous  it  should  be  supported  by  means  of  a  binder. 
The  upper  part  of  the  body  should  also  be  supported  until 
the  head  engages  in  the  superior  strait ;  in  some  cases  it 
may  be  necessary  to  put  the  woman  into  Walcher's  posi- 
tion (see  §  4).  The  diagnosis  is  finally  confirmed  and  the 
treatment  completed  by  the  above-mentioned  external 
pressure  on  the  head.  The  general  indications  for  opera- 
tion, as  far  as  the  pelvis  is  concerned,  have  been  mentioned 
in  §  20,  under  Xo.  2a,  foot-note.  The  special  indications 
will  be  found  in  the  AUclh  of  Labor  and  Operative  Ob- 
stetrics. 

If  the  head  fails  to  descend  and  is  still  movable,  or  if 
it  is  impossible  to  convert  a  face  presentation  with  the 
chin  posterior  into  a  vertex  presentation,  version  is  indi- 
cated if  the  child  is  alive  and  the  true  conjugate  is  not 


Tab.  56. 


Fig.  120 


LlUi.  Anst  F.  Reichhold.  Mujxch^ji. 


Tab.  57. 


Fig.   123.       Lilh.An.s1  F.  Reichhold,Munchm. 


CO 


PECULIARITIES  OF  DEFORMED  PELVES.       209 

less  than  2J  or  3}  in.  (7  or  8  cm.).  If,  under  the  same 
conditions,  the  head  has  entered  the  pelvis  and  is  immov- 
able, the  forceps  should  be  used.  Embryotomy  is  indicated 
if  the  true  conjugate  is  not  less  than  2f  or  2J  in.  (6.5  or 
5.5  cm.)  (see  §  20,  No.  2a,  foot-note).  If  the  contraction 
surpasses  this  limit  it  constitutes  an  absolute  indication 
for  Cesarean  section. 

I  19.  ANATOMICAL  AND  OBSTETRICAL  PECULIARS 
TIES  OF  DEFORMED  PELVES. 

Fig.  50  (Plate  25),  Generally  equally  contracted  pelvis  (text,  §  20, 
No.  1). 

Fig.  118.  Flat  non-racliitic  pelvis  (text,  ^  20,  No.  2a). 

Fig.  119.  Flat  rachitic  pelvis  (text,  ?  20,  No.  3a). 

Fig.  120.  Generally  contracted  flat  rachitic  pelvis  (text,  ^  20,  No.  36). 

Fig.  121.  Flat  rachitic  jielvis  of  high  degree  (text,  ^  20,  No.  3a). 

Fig.  122.  Compressed  rachitic  pseudo-osteomalacic  pelvis  (text,  §  20, 
No.  3c). 

Fig.  123.  Compressed  osteomala(;ic  pelvis  (text,  §  20,  No.  4). 

Fig.  124.  Zone  of  Ossification  in  a  Normal  Epiphysis  (microscopical)  : 
1,  hyaline  cartilage;  2,  zone  of  beginning  proliferation  of  the  cartilage; 
3,  columns  of  cartilage-cells  arranged  in  rows;  4,  columns  of  enlarged 
cartilage-cells ;  5,  first  zone  of  calcification ;  6,  layer  of  osteoblasts  in 
first  zone  of  ossification  ;  7,  fully  developed  cancellous  tissue  (spongiosa) ; 
8  and  9,  blood-vessels  in  transverse  and  longitudinal  section. 

Fig.  125.  Zone  of  Ossification  in  a  Rachitic  Epiphysis  (microscopical) : 
1,  transition  of  normal  hyaline  cartilage  to  proliferating  cells :  2,  zone 
of  cartilage-cells  arranged  in  roAvs ;  3,  cellulofibrous  medullary  spaces 
containing  blood-vessels  in  the  region  of  the  proliferated  and  enlarged 
cartilage-cells;  4,  island  of  calcified  cartilaginous  tissue;  5,  columns  of 
osteoid  and  fully  developed  calcified  bone-tissue;  6,  columns  of  osteoid 
tissue  not  containing  lime-salts;  7,  like  3,  with  the  blood-vessel  in  trans- 
verse section. 

Fig.  126.  Microscopical  Section  through  an  Osteomalacic  Bone :  1, 
remains  of  calcified  bone-substance;  2,  decalcified  bone-substance;  3, 
large  medullary  spaces  due  to  the  disappearance  of  bone-substance;  4, 
Haversian  canals  (text,  ^  20.  Nos.  3  and  4). 

Fig.  127.  Conical  Abdomen  (Spitzbauch),  showing  the  area  of  dulness 
(from  a  case  of  polyhydramnion  of  Kiistner). 

Fig.  128.  Pendulous  Abdomen,  first  degree. 

Fig.  129.  Pendulous  Abdomen,  second  degree  (^?  15c,  20,  Nos.  3  and  4). 

Fig.  130.  Cephalic  Presentation  at  the  brim  in  a  flat  rachitic  pelvis 
in  Nagele's  obliquity.     Second  vertex  presentation,  or  presentation  of 
the  anterior  parietal  bone  (text,  §  20,  No.  3). 
14 


I 


210 


Tab.  60. 


Fig.  132. 

Lith.Anst  E  Reichhold.  Miinchen. 


^ 


CO 

CO 


o 


Tab.  62. 


Fig.  134 


Fig.  136. 


Liih.Anst  E  Reirhhold,  Munchen.. 


PECULIARITIES   OE  BEEOBMED  PELVES.        211 

Fig.  131.  Dia^am  Shomng  the  Curve  of  tlie  Sacrum  in  normal, 
rachitic,  and  osteumalacic  pelves,  with  the  changes  iu  tlie  position  of  the 
symphysis.  Presentation  of  the  head  as  in  the  preceding  figure,  seen 
in  sagittal  section  in  a  flat  rachitic  pelvis  (text,  §  20,  Xos.  3  and  4). 

Fig.  132.  Shows  the  Shape  of  the  Skull  described  in  Figs.  130  and 
131 :  depression  of  the  posterior  parietal  bone  by  the  promontory,  fract- 
ures, characteristic  bulging  of  the  anterior  left  parietal  bone  (text,  §  20, 
No.  3). 

Fig.  133.  Brow  Presentation  in  a  case  of  hydrocephalus  with  gener- 
ally and  flat  contracted  pelvis.  Complete  rupture  of  the  uterus  resulted. 
The  position  shown  in  the  figure  corresponds  to  what  was  found  at  the 
autopsy. 

Fig.  133a.  Hydrocephalus  of  Fig.  133. — See,  also,  illustration  of  the 
rupture  in  Figs.  1.52  and  1-53  (text.  ^  20,  Xo.  1;. 

Fig.  1.S4.  Infantile  or  Undeveloped,  Funnel-shaped  Pelvis,  with  oval 
superior  strait  and  contracted  outlet    text.  ^  20.  5  7  . 

Fig.  51  (Plate  25).  A  Fetal  Undeveloped,  "  Decubital"  Pelvis,  funnel- 
shaped  (text,  §  20,  Xos.  56  and  8). 

Fig.  135.  RacMtic-kyphotic,  Funnel-shaped  Pelvis,  with  symmetrical 
assimilation — so-called  "  intercalated  vertebra":  better.  ''txansiTional 
vertebra,''  bilateral  formatiou  (text,  5  20.  Xo.  11). 

Fig.  136.  Kyphotic.  Funnel-shaped  Pelvis,  with  double  promontory 
(text,  §  20,  Xo.  5c). 

Fig.  137.  Asjomnetrical  assimilation  pelvis,  not  obliquely  contracted. 
The  lumbosacral  "transitional  vertebra"  forms  part  of  the  sacrum  on 
the  left,  and  part  of  the  lumbar  vertebra  on  the  right  side  (text,  §  20, 
Xo.  11). 

Fig.  138.  Double  Promontory  in  Sagittal  Section  (text,  §  20,  Xos. 
5  and  11). 

Fig.  139.  Obliquely  Contracted  Pelvis,  due  to  rachitic  scoliosis  (Sfc) : 
the  two  lowest  lumbar  vertebrae  indicate  the  compensatory  direction 
(text,  ^  20,  Xo.  6n). 

Fig.  140.  Superior  Strait  of  a  Right  Obliquely  Contracted  Pelvis, 
the  left  half  representing  ''dead  space '"  for  the  passage  of  the  head 
(text,  §  20,  Xo.  6). 

Fig.  141.  Right  Obliquely  Contracted  Pelvis,  due  to  ankylosis  of  the 
right  hip  following  coxiti-    text,  ^  2<:i.  Xo.  6'7  . 

Fig.  142.  Left  Obliquely  Contracted  Pelvis,  due  to  synostosis  of  the 
alae  of  the  sacrum  on  tlie  ris^Iit  side  'text,  §  20.  6b'. 

Fig.  143.  Spondylolisthetic  Pelvis    text.  ?  20.  Xo.  10). 

Fig.  144.  Robert's  Transversely  Contracted  Pelvis   text.  ^  20.  Xo.  7). 

Fig.  145.  Flat,  Anteroposteriorly  Contracted  Pelvis,  due  to  luxation 
of  both  femora  backward  and  upward  (after  Schauta — text,  §20,  Xo.  8). 

Fig.  146.  Transversely  Contracted  Oval  Pelvis,  due  to  double  talipes 
varus  ^after  Schauta— text,  i  20.  Xo.  S). 

Fig.  14T.  Split  Pelvis  or  Pelvis  Flssa  (after  Schauta— text,  §  20,  X'o.  9). 


212  DEFORMITIES  OF  THE  PELVIS. 

Fig.  148.  Acanthopelys  (spiny  pelvis)  in  rachitis  ;  at  the  iliosacral 
articulation  on  the  right  (29)  and  at  both  iliopubic  synostoses  (30)  (text, 
g  20,  Nos.  3  and  12). 

Fig.  149.  Exostosis  as  a  result  of  fracture  of  the  iliac  bone  (after 
V.  Winckel— text.  ^20,  No.  4). 

Fig.  150.  A  Cystic  Enchondroma,  seen  from  above  (Behm's  case — text, 
§20,  No.  13). 

(Original  drawings  from  preparations  in  the  Munich  Gynecological 
Clinic:  133,  133a  from  the  Heidelberg  Gynecological  Clinic  ;  150  drawn 
from  a  cast ;  122  after  K.  Schroder  ;  149  after  v.  Winckel ;  124-126  after 
Ziegler;  145-147  after  Schauta). 

CLASSIFICATION    AND     DESCRIPTION    OF    DEFORMED 

PELVES. 

Generally  Contracted  Pelves. 

No.  1. — Generally  equally  contracted  pelvis. —  Varieties: 

No.  \a. — Juvenile  pelvis,  seen  usually  in  well-grown 
individuals  (Fig.  50). 

No.  lb, — Masculine  pelvis,  simple  contracted,  with 
heavy  masculine  bones. 

No.  Ic. — Dwarf  pelvis  (pelvis  nana). 

Etiology. — Arrest  of  development,  without  rachitis. 

Character istics. — These  peh'es  resemble  the  normal  in 
shape  and  symmetry  ;  the  bones  are  normal  in  thickness ; 
they  represent,  as  a  rule,  a  simple  miniature  of  a  normal 
pelvis.     In  some  there  is  infantile  arrest  of  development. 

In  the  infantile^  (No.  la)  the  promontory  is  high  and 
not  very  prominent,  the  sacrum  straight,  and  the  inclina- 
tion of  the  symphysis  diminished.  On  the  other  hand, 
the  transverse  diameters  are  normal.  The  distance  be- 
tween the  posterior  spines  is  increased. 

In  the  masculine  pelvis  the  bones  are  extraordinarily 
thick  and  heavy  ;  tlie  genitalia  are  often  infantile. 

In  the  dwarf  pelvis  the  bones  are  slender  and  fragile  ; 
the  proportions  are  normal ;  tliere  is  a  marked  lateral 
curvature  of  the  anterior  surface  of  the  sacrum.  In  the 
infantile  variety  the  cartilaginous  junctions  between  the 

1  This  variety  not  to  be  confounded  with  the  ''  fetal  or  undeveloped  " 
funnel-shaped  pelvis. — Trans. 


Tab.  63. 


Fig.  137. 


Fig.  139. 


Lith .  Ami  E  Retdihold,  Miindim. 


Tab.  64. 


142. 


10      3b 


Fig.  143, 


35 

Fig.  144- 

Lith.Ansi  F  ReicMwld.Mundmi. 


Tab.  65. 


Fig..  147. 


Ltth .  Anst  E  ReidihoLd,  Miinchen. 


Tab.  66. 


Fig.  148. 


Fig.  150. 


lith..Anst  F  Reichhold,  Miindim. 


GENERALLY  CONTRACTED  PELVES.  213 

divisions  of  the  sacrum  and  iliac  bones  persist.  The 
sacral  alie  are  narrow  in  proportion  to  the  body  of  the 
vertebra.  The  promontory  is  flat.  The  transverse  meas- 
urements are  normal. 

No.  Id. — Generally  equally  contracted  rachitic  pelvis. 

Etiology. — Rachitis. 

Characteristics.— AW  the  measurements  are  smaller, 
especially  the  distance  between  the  spines.  It  differs 
from  the  juvenile  pelvis  by  its  angular,  unsightly  out- 
line (cf.  Fig.  50),  by  the  prominence  of  the  crest  of  the 
pubis,  by  tlie  rachitic  form  and  position  of  the  sacrum 
(see  under  "Rachitic  Pelves^'),  and  by  the  increasing 
expansion  at  the  outlet.  Probably  not  so  very  rare  as  is 
usually  stated.  The  relation  between  the  spines  and  crest 
is  normal  ;  promontory  not  prominent ;  diagonal  con- 
jugate shortened  ;  distance  between  the  posterior  spines 
increased — hence  not  rachitic — perimeter  of  the  pelvis 
about  2|^in.  (7  cm.)  less.  Even  when  all  the  diameters 
are  shortened  by  f  in.  (2  cm.)  there  is  not  much  more 
impediment  to  labor  than  usual. 

Diagnosis. — Conjugata  vera  between  3|-  and  4J  in.  (9J 
and  10^  cm.) ;  never  less  than  6^  in.  (8  cm.)  in  juvenile 
pelves. 

Influence  on  Pregnancy. — Uterine  displacements  are 
rare  because  the  lower  portion  of  the  fetus  succeeds  in 
entering  the  true  pelvis  tow^ard  the  end  of  pregnancy  ; 
hence,  also,  cephalic  presentation  is  the  rule. 

Labor. — On  account  of  the  uniform  resistance  encoun- 
tered at  the  inlet  the  chin  is  brought  nearer  the  chest,  in 
other  words,  the  head  is  strongly  flexed  (Roderer's  ob- 
liquity). This  is  often  combined  with  Solayres'  obliquity 
or  engagement  in  the  oblique  diameter.  Advance  of  the 
plane  (12|  in.  =  32  cm.)  corresponding  to  the  lesser  ob- 
lique diameter  of  the  fetal  skull  (3|-  in.  =  9.5  cm.) ;  the 
lesser  fontanel  can  be  readily  palpated. 

Presentation  of  the  greater  fontanel  (i.  e.,  occipito- 
frontal periphery — 13f  in.  =  34  cm. — corresponding  to 
the  occipitofrontal  diameter — 4|  in.  =  12  cm.)  or  of  the 


214  DEFORMITIES  OF  THE  PELVIS. 

brow  (Fig.  133)  is  very  rare  and  most  unfavorable, 
especially  if  the  uterus  is  displaced  to  the  right;  hence, 
in  such  a  case  the  woman  must  not  be  allowed  to  lie  on 
her  right  side. 

In  pelvic  presentations,  which  are  rare,  the  head  is 
delivered  in  an  analogous  attitude  of  flexion. 

The  progress  of  the  head  is  very  apt  to  become  arrested 
(paragomphosis) ;  labor-pains  soon  cease  and  pressure- 
necroses  result.  In  rare  cases  the  uterus  may  be  ruptured. 
Eclampsia  is  extraordinarily  frequent,  owing  to  the  pres- 
sure on  the  ureters.     Marked  caput  succedaneum. 

Treatment. — If  the  true  conjugate  is  between  Z\  and 
3f  in.  (8  and  9  cm.)  labor  should  be  induced  prematurely 
in  the  thirty-fifth  or  thirty-sixth  week  ;  or  the  head  may 
be  pressed  down  firmly  on  the  brim  of  the  pelvis  for  one 
and  one-half  minutes,  once  a  week  from  the  time  the 
child  begins  to  be  viable  (for  size  and  compressibility  of 
fetal  skull,  see  §  2) ;  or  forceps  may  be  applied.  If  the 
conjugate  measures  over  3f  in.  (9  cm.),  an  expectant  policy 
may  be  pursued,  the  woman  being  placed  on  the  s;de 
toward  which  the  occiput  presents.  Version  is  applicable 
only  to  exceptional  cases.  If  the  fetus  is  dead  embryot- 
omy is  to  be  performed. 

Table  of  Indications  foe  the  Induction  of  Premature  Labor. 

Conjn.eata  vera  31:  in.  (8  cm.)  in  the  35th  week. 

Conjiisata  vera  3  to  3^  in.  {Ih  to  8  cm.)  in  the  31st  to  34th  week. 

Conjugata  vera  3  in.  (7i  cm.)  before  the  30th  week. 

This  applies  to  flat  pelves  as  well.  If  the  true  conjugate 
is  2J  in.  (6  cm.)  the  induction  of  abortion  is  usually 
necessary. 

Table  of  Indications  for  the  Application  of  Forceps  and  for 

Embryotomy. 

Peine  Contraction.  Conjufiata  Vera. 

First  degree,  3^  to  4    in.  (8.,5  to  10   cm.) ; 

Second  degree,  2^  to  3|  in.  (7     to  8.5  cm.) ; 

Third  degree,  2^  to  2|  in.  (5.5  to  7     cm.). 

With  a  conjugate  of  2-|  in.  (7  cm.)  the  application  of 


ANTEROPOSTERIORLY  CONTRACTED  PELVES.   215 

forceps  is  possible  under  favorable  conditions ;  3^  (8  cm.) 
is  the  usual  limit. 

If  the  conjugate  is  less  than  2|-  in.  (6.5  cm.)  in  a  gen- 
erally equally  contracted  pelvis,  or  less  than  2^  in.  (5.5 
cm.)  in  a  flat  pelvis,  even  a  mutilated  child  cannot  be 
extracted. 

Spontaneous  delivery  at  term  has  occasionally  been 
observed  in  flat  pelves  with  a  true  conjugate  of  less  than 
3j  in.  (8  cm.). 

These  indications  being  based  on  the  length  of  the  true 
conjugate  are,  of  course,  influenced  by  the  force  of  the 
labor-pains,  the  possibility  of  properly  preparing  the 
parturient  tract,  and  all  the  other  minor  determining 
factors. 

Anteroposteriorly  Contracted  Pelves. 

(Figs.  118-122,  125,  127-132). 

No.  2. — Flat  non-racliitic  pelvis. 

Xo.  2a. — Simple  flat  non-rachitic  (erroneously  desig- 
nated Deventer's)  pelvis  (Fig.  118). 

Etiology. — Arrested  development.  The  most  frequent 
pathological  form  is  probably  due  more  to  an  inherited 
tendency  than  to  overwork  and  the  carrying  of  heavy 
weights  in  early  childhood. 

Charade rhtics. — Shortening  of  the  conjugata  vera  at 
the  inlet,  and,  to  a  lesser  degree,  of  the  anteroposterior 
diameter  of  the  true  pelvis  ;  in  other  words,  the  sacrum 
as  a  whole  is  displaced  forward  without  rotation  around 
its  transverse  axis  (as  in  the  rachitic)  and  reduced  in  size 
in  all  its  parts.  As  a  result  the  posterior  superior  spines 
project  far  backward  and  the  distance  between  them  is 
diminished  ;  the  opposite  condition  obtains  in  the  equally 
contracted  pelvis. 

Slight  inclination  of  the  sacrum.  Often  double  prom- 
ontory (Fis:.  138).  Relation  between  spines  and  the  crest 
normal,  hence  not  rachitic.  Distance  between  the  poste- 
rior superior  spines  d  iminished,  transverse  diameter  slightly, 
external  and  diagonal  conjugates   markedly  diminished. 


216  DEFORMITIES  OF  THE  PELVIS. 

In  some  cases  the  deformity  can  be  detected  with  absolute 
certainty  only  by  Skutsch's  method  (Figs.  44  and  56). 

Influence  on  Pregnancy. — Pendulous  abdomen  and  ab- 
normal positions  and  presentations  of  the  fetus  are  more 
frequent  than  in  generally  contracted  pelves. 

Labor. — The  width  of  the  pelvis  being  normal,  the 
head  engages  with  the  sagittal  suture  in  the  transverse 
diameter  of  the  pelvis  and,  as  it  slowly  effects  an  entrance, 
undergoes  two  different  rotations,  as  follows  : 

(a)  The  posterior  parietal  bone  is  pushed  up  toward  the 
promontory,  so  that  the  sagittal  suture  is  brought  nearer 
to  the  promontory  (Nagele's  obliquity,  see  Fig.  130). 

(6)  The  small  bitemporal  diameter  (3^  in.  =  8  cm.) 
rotates  into  the  true  conjugate,  that  is  to  say,  there  occurs, 
in  addition  to  Nagele's  obliquity  or  presentation  of  the 
anterior  parietal  bone,  a  presentation  of  the  greater  fon- 
tanel, which  can  be  readily  palpated.  In  this  transverse 
position  the  head  descends  to  the  pelvic  outlet.  In  lumbo- 
sacral lordosis,  especially  in  rachitic  pelves  with  a  high 
degree  of  scoliosis  and  a  greatly  contracted  conjugate,  the 
head  enters  the  brim  in  extreme  flexion  (as  in  the  ,2"en- 
erally  contracted  pelvis)  in  the  extramedian  position  (Fig. 
140),  that  is,  fixed  in  one-half  of  the  pelvis. 

In  breech  presentations  the  prognosis  is  most  favorable 
when  the  chin  engages  first ;  in  other  words,  the  smallest, 
suboccipitobregmatic  periphery  (12f  in.  =  32  cm.) ;  other- 
wise the  chin  is  apt  to  catch  on  the  horizontal  ramus  of 
the  pubis. 

Diagnosis. — Conjugata  vera,  3^  to  4  in.  (8  to  10  cm.), 
usually  more  than  3|  in.  (9  cm.). 

In  calculating  the  true  conjugate  from  the  diagonal 
conjugate  in  flat  pelves  it  must  be  remembered  that  the 
inclination  of  the  symphysis  is  much  less,  and  hence  the 
diagonal  conjugate  relatively  greater.  Instead  of  |-  in. 
(1.5  cm.),  from  J  to  1^  in.  (1.8  to  3  cm.) — in  rachitic  pelves 
— must  be  subtracted  from  the  diagonal  conjugate  to  obtain 
the  true  conjugate. 

Treatment. — If  the  true  conjugate  is  between  3 J  and 


ANTEROPOSTERIORLY  CONTRACTED  PELVES.   217 

3f  in.  (8  and  8.5  cm.),  induction  of  premature  labor 
between  the  thirty-fourth  and  thirty-sixth  weeks,  or  ver- 
sion sub  partn  is  indicated.  The  forceps  is  applied  only 
when  the  head  is  transversely  placed  deep  in  the  excava- 
tion (hollow  of  sacrum),  or  after  it  has  passed  the  superior 
strait  and  the  force  of  the  labor-pains  is  beginning  to 
diminish.  In  primiparse  it  is  better  to  wait,  as  the  head  is 
small  and  labor-pains  are  usually  vigorous,  later,  forceps ; 
in  multipara?,  version.  The  unfavorable  but  rare  presenta- 
tion of  the  posterior  parietal  bone  should  be  corrected 
when  the  head  first  enters  the  inlet ;  otherwise  version, 
but  not  forceps.  The  woman  should  be  placed  on  the  side 
toward  which  the  brow  presents,  so  as  to  favor  the 
entrance  of  the  smaller,  anterior  portion  of  the  head 
(sinciput)  into  the  inlet. 

The  danger  of  rupture  of  the  uterus  is  greater  than  in 
generally  contracted  pelves. 

The  treatment  mentioned  under  Xo.  1,  "  generally  con- 
tracted pelves,''  of  forcing  the  head  into  the  pelvic  inlet 
during  the  latter  part  of  pregnancy,  is  useful  in  this  variety 
of  deformed  pelvis. 

Xo.  2b. —  Generally  and  fiat  contracted,  non-rachitic 
j)elvis  (generally  unequally  contracted,  non-rachitic  pelvis). 

Etiology. — Arrest  of  development. 

Characteristics. — Shortening  of  all  the  diameters,  espe- 
cially of  the  anteroposterior  at  the  inlet,  due  not  to  ante- 
rior displacement  of  the  sacrum,  but  to  the  imperfect 
development  of  the  portions  of  the  innominate  bone  which 
surround  the  inlet.  Probably  not  so  very  rare  as  is  usually 
stated.  The  promontory  is  very  high  and  displaced  back- 
ward, hence  from  f  to  1  in.  (2  to  2.5  cm.)  must  be  sub- 
tracted from  the  diagonal  conjugate  in  calculating  the 
conjugata  vera. 

The  infiuence  on  labor  is  the  same  as  in  the  correspond- 
ing rachitic  form. 

Xo.  3. — Flat  rachitic  pelvis. 

No.  3a. — Simple  flat  rachitic  pelvis  (Figs.  119,  121, 
125,  127-132). 


218  DEFORMITIES  OF  THE  PELVIS. 

Etiology. — Rachitis.  The  proliferation  of  cartilage  and 
bone-cells  is  normal,  but  there  is  defective  deposition  of 
lime  salts,  or  the  lime-salts  already  deposited  are  absorbed 
because  the  blood-vessels  in  the  bone-forming  structures 
are  increased  in  number  and  overfilled  with  blood,  and 
thus  bring  about  a  more  rapid  liquefaction  of  the  cartilage 
and  the  already  ossified  tissues  (cf.  Fig.  124  with  Fig. 
125). 

The  effect  is  twofold  :  1.  Distortion  of  the  skeleton  by- 
pressure  and  traction,  as  explained  in  §  4.  The  effect  is 
exaggerated  on  account  of  the  softness  of  the  bones.  2. 
Infantile  arrest  of  development  in  the  insufficiently  nour- 
ished bones.  Hereditary  tendency  may  be  present  in 
some  cases. 

CharaGteristics. — The  distance  between  the  anterior 
spines  is  equal  to,  or  even  greater  than,  the  distance 
between  the  crests,  because  the  ilia  are  flattened  and 
pushed  backward.  This  condition  of  the  iliac  bones  is 
the  result  of  flattening  and  of  the  absolute,  or  at  least 
relative,  increase  in  the  separation  of  the  two  iliac  bones. 
Owing  to  lordosis  of  the  lumbar  vertebrse  the  sacrum 
sinks  forward  into  the  pelvis,  the  effect  of  the  excessive 
weight  of  the  trunk  in  childhood  w4ien  the  rachitic  soften- 
ing process  is  most  active.  The  posterior  superior  spines 
project  backward  and  the  distance  between  them  is  dimin- 
ished. There  is  backward  displacement  of  those  portions 
of  the  sacrum  which  articulate  with  the  iliac  bones  (the 
first  to  the  third  vertebra) ;  the  remaining  portions  of 
the  sacrum  and  coccyx  are  straighter  than  normal  (cf. 
Fig.  13).  Like  most  of  the  other  bones  the  sacrum  is 
diminished  in  size.  Owing  to  the  pull  of  the  ligaments 
and  muscles  there  is  even  a  greater  increase  in  the  trans- 
verse diameter  at  the  outlet.  The  pubic  arch  is  usually 
more  than  100  degrees.  The  symphysis  is  perpendicular 
and  therefore  tends  to  lengthen  the  diagonal  conjugate;  in 
common  with  the  other  walls  of  the  true  pelvis  it  is 
diminished  in  height.  From  a  practical  point  of  view  it 
is  important  to  note  that  all  the  synostoses,  synchondroses, 


ANTEROPOSTERIORLY  CONTRACTED  PELVES.   219 

and  synarthroses,  etc.,  form  sharp,  projecting,  bony  points 
which  mav  easilv  rupture  the  soft  parts  (cf.  under  ^' Acan- 
thopelys,''  §  20,' Xo.  12,  and  Fig.  148). 

Influence  on  Pregnancy. — There  is  an  extraordinary 
tendency  to  uterine  displacements  :  anteversion  and  ante- 
flexion with  pendulous  abdomen  (see  ^  15c  and  Figs.  99, 
127-129),  or  retroversion  and  retroflexion,  which  may 
lead  to  serious  incarceration  under  the  promontory  (see  § 
\ba  and  Figs.  102,  103,  105).  Eclampsia,  on  the  other 
hand,  is  rare,  probably  because  the  ureters  are  protected 
from  pressure  by  their  position  in  the  hollow  spaces  to 
either  side  of  the  convex  body  of  the  sacral  vertebra. 
But  for  this  very  reason  there  is  a  greater  predisposition 
to  prolapse  of  an  extremity  or  of  the  umbilical  cord  (five 
times  more  frequent).  Owing  to  the  length  of  time  con- 
sumed in  overcoming  the  difficulties  at  the  inlet  or  to  an 
abnormal  presentation  an  excessive  amount  of  amniotic 
fluid  is  produced,  and  rupture  of  the  membranes  usually 
occurs  prematurely,  that  is,  before  engagement  of  the 
head  in  the  superior  strait;  in  56  per  cent,  of  the  cases  it 
occurs  only  after  the  os  is  fully  dilated.  The  head  engages 
in  the  same  way  as  in  the  flat  non-rachitic  pelvis,  which 
has  been  described  (cf.  preceding  form,  2a,  Figs.  130-132). 
The  muscular  effort  is  usually  much  greater,  and  the 
danger  of  rupture  of  the  soft  parts  or  of  the  pelvic  joints, 
especially  at  the  sharp  projections  described,  correspond- 
ingly increased  (see  §  20,  Xo.  12,  and  Fig.  148).  Great 
liability  to  localized  necrosis  and  fistula  formation.  Vertex 
presentations  are  less  frequent  by  10  per  cent. ;  the  dura- 
tion of  labor  is  increased  by  50  per  cent.  Caput  succe- 
daneum  very  pronounced  ;  the  outline  of  the  entire  skull 
suffers  a  corresponding  degree  of  disfigurement  and  injury; 
the  posterior  parietal  bone,  which  is  forced  against  the 
promontory,  receives  an  indentation,  or  even  a  fracture, 
and  subdural  hematomata  are  formed  (Figs.  130-132). 
Labor-pains  are  irregular,  both  on  account  of  the  purely 
mechanical  resistance  and  indirectly  on  account  of  circula- 
tory disturbances. 


220  DEFORMITIES  OF  THE  PELVIS. 

Diagnosis. — Conjugata  vera  is  usually  above  3J  in.  (8 
cm.)  (cf.  tables  and  remarks  under  No.  1,  generally  con- 
tracted pelves).  General  rachitic  habit.  Flat  receding 
iliac  bones.  The  distance  between  the  anterior  superior 
spines  is  equal  to,  or  greater  than,  the  distance  between  the 
crests ;  the  promontory  is  easily  palpated.  External  and 
diagonal  conjugates  are  shortened;  from  f  to  IJ  in.  (1.8 
to  3  cm.)  must  be  subtracted  in  calculating  the  conjugata 
vera.  The  descent  of  the  promontory  may  also  be  inferred 
from  the  prominence  of  the  posterior  superior  spines  and 
the  diminution  in  the  distance  between  them. 

Treatment. — The  same  as  for  flat  non-rachitic  pelves. 
It  is  to  be  remembered  that  owing  to  the  perpendicular 
position  of  the  symphysis  the  difference  between  diagonal 
and  the  true  conjugate  is  greater  (|^  in.  =  2  cm.)  than  it 
is  in  non-rachitic  pelves.  The  measurements  of  the  out- 
let are  to  be  taken  into  account,  as  has  been  explained 
under  No.  5 ;  in  certain  cases  the  perforator  may  be  re- 
quired instead  of  the  forceps. 

No.  36. — Generally  contracted,  flat  rachitic  pelvis 
(Fig.  120). 

Etiology. — Rachitis.  The  softer  the  bones  and  the 
earlier  the  disease  makes  its  appearance,  the  deeper  and 
more  anterior  is  the  position  of  the  body  of  the  first  sacral 
vertebra,  the  greater  tlie  compression  of  the  lateral  walls 
of  the  pelvis  in  front  by  the  femora,  and  the  more  imper- 
fect the  development  of  all  the  bony  parts. 

Characteristics. — Transitional  form  between  the  simple 
flat  rachitic  and  the  collapsed  '^  pseudo-osteomalacic 
pelvis,"  inasmuch  as  it  owes  its  shape  to  an  earlier  and 
more  intense  softening  process  than  to  that  which  produces 
the  "simple  flat  rachitic  pelvis,"  and  has,  therefore,  suf- 
fered a  lateral  compression  in  addition  to  the  flattening, 
the  compression  being  greater  in  the  transverse  direc- 
tion than  in  the  conjugate  on  account  of  the  pressure  of 
the  femora.  The  result  is  a  triangular  shape  (Fig.  120) 
of  the  inlet ;  in  other  respects  it  bears  all  the  marks  of  a 
"simple  flat  rachitic  pelvis"  in  contradistinction  to  the 


ANTEROPOSTERIORLY  CONTRACTED  PELVES.    221 

rarer  non-rachitic,  generally  equally,  and  flat  contracted 
pelves.  The  outlet,  however,  is  smaller,  hence  also  the 
distorting  effect  of  the  muscles  and  ligaments  Avhich  is 
seen  even  in  the  flat  pelvis  is  greater :  the  psoas  and 
sacrospinal  muscles  act  on  the  lumbar  lordosis  and  on  the 
upper  portion  of  the  sacral  bone,  which  they  tend  to 
straighten;  the  iliosacral  bones  counteract  the  outward 
rotation  of  the  iliac  bones. 

Influence  on  Pregnancy. — The  promontory  projects  far 
into  the  pelvic  cavity,  leaving  a  greater  amount  of  ^Most" 
(dead)  space  on  either  side  for  the  uterus  and  its  contents, 
but  the  anterior  half  of  the  pelvis  available  for  this  purpose 
has  the  same  special  characteristics  as  the  ^^  generally 
equally  contracted  pelvis,"  hence  there  is  an  extraordinary 
tendency  to  anteflexion  with  pendulous  abdomen  (Figs.  99 
and  129),  abnormal  positions  and  presentations  of  the 
fetus,  and  anomalies  in  the  shape  of  the  uterus  (trans- 
versely elliptical,  round,  or  obliquely  distorted). 

Labor. — ^The  head  in  this  variety  also  engages  with 
the  sagittal  suture  in  the  transverse  diameter  of  the  inlet ; 
eventually  the  occiput  descends  as  in  the  generally  con- 
tracted pelvis,  the  posterior  parietal  bone  usually  present- 
ing. Presentation  of  the  anterior  parietal  bone  is  very 
iinfavorx^ble.  Rotation  around  the  small  oblique  diameter 
occurs  very  late. 

In  pelvic  presentations  the  chin  is  the  first  to  enter  the 
inlet,  the  head,  therefore,  passes  in  this  case  also  in  the 
smallest  or  snboccipitobregmatic  periphery  (12J  in.  =  32 
cm.)  ;  any  other  mechanism  is  most  unfavorable.  Prolapse 
of  an  extremity  or  of  the  cord  is  readily  explained  by 
the  "  lost  (dead)  angles  "  on  either  side  of  the  promontor}^ 
There  is  great  liability  to  rupture,  both  of  the  soft  parts 
and  of  the  pelvic  joints ;  marked  caput  succedaneum  ; 
injury  to  the  parietal  bone  by  the  promontory  (subcutane- 
ous and  subdural  hematomata.  Figs.  130-132),  the  result 
of  the  extraordinary  duration  of  labor  and  the  triangular 
shape  of  the  inlet  so  ill  adapted  to  the  fetal  skull  (Fig.  120). 

Diagnosis. — Conjugata  vera    often    less    than    3^   in. 


222  DEFORMITIES  OF  THE  PELVIS. 

(8  cm.)  (see  tables  and  remarks  under  No.  \,  generally 
contracted  pelves). 

The  general  signs  of  rachitis  are  more  marked  ;  the 
stature  is  small.  All  the  signs  of  a  simple  flat  rachitic 
pelvis  and,  in  addition,  shortening  of  all  the  transverse 
diameters,  even  those  of  the  outlet,  are  present.  The 
iliopectineal  line  can  be  readily  palpated. 

Treatment. — If  the  true  conjugate  measures  3^  to  3f  in. 
(8  to  9  cm.)  premature  labor  should  be  induced  between 
the  tliirty-second  and  thirty-sixth  weeks;  or,  if  the  poste- 
rior parietal  bone  presents  and  the  occiput  has  descended 
into  the  hollow  of  the  sacrum,  the  forceps  may  be  used. 
In  presentation  of  the  anterior  parietal  bone  usually,  and 
if  the  true  conjugate  is  less  than  3J  in.  (8  cm.),  always, 
craniotomy  or  Cesarean  section  is  called  for. 

In  primiparse  with  only  a  moderate  degree  of  contrac- 
tion it  is  advisable  to  defer  the  induction  of  premature 
labor  until  the  thirty-eighth  or  fortieth  week  (Ahlfeld). 

Collapsed  Pelves. 

(Figs.  122,  126,  128.) 

No.  3c. —  Collapsed  racJiitic  or  pseudo-osteomalacie  pelvis 
(Fig.  122). 

Etiology. — Rachitis.  When  the  bones  are  very  soft 
and  the  already  formed  layers  of  lime-salts  undergo 
secondary  liquefaction,  the  acetabula  and  promontory, 
being  most  exposed  to  pressure  and  traction,  show  the 
effect  of  compression  most  markedly.  The  symphysis  is 
protruded  in  the  form  of  a  beak,  while  the  iliac  bones 
are  bent  backward. 

Characteristics. — The  inlet  resembles  that  of  the  osteo- 
malacic pelvis,  being  shaped  like  a  heart  in  cards. 
Marked  descent  of  the  promontory  ;  inward  compression 
of  the  acetabula  and  beak-like  prominence  of  the  symphy- 
sis. The  small  iliac  bones  are  flat  and  displaced  back- 
ward. The  tuberosities  of  the  ischium  are  approxi- 
mated. 

Influence  on  Pregnancy. — During  pregnancy  the  posi- 


COLLAPSED  PELVES.  223 

tion  of  the  uterus  is  high,  from  failure  of  the  presenting 
part  to  enter  the  superior  strait,  oblique  positions  of  the 
fetus  arise,  etc. 

Labor. — Spontaneous  and  forceps  delivery  are  equally 
impossible  in  most  cases. 

Diagnosis. — Extraordinarily  deep  position  of  the  prom- 
ontory ;  the  symphysis  is  beak-shaped ;  the  characteris- 
tic outline  of  the  iliopectineal  line  is  readily  palpable. 
Manifestations  of  rachitis  are  present.  The  real  conjugata 
vera  is  no  criterion  for  the  possibility  of  labor. 

Treatment. — Cesarean  section  is  required  in  almost 
every  instance. 

No.  4. — Osteomalacic  collapsed  pelvis  (pelvis  halis- 
teretica,  Fig.  123). 

Etiology. — Osteomalacia.  The  lime-salts  in  the  per- 
fectly developed  bone  of  the  adult  undergo  absorption 
and  are  not  replaced  by  cartilage  as  in  the  child ;  nothing 
remains  but  the  fibrous  tissue  devoid  of  lime-salts  (Fig. 
126).  In  contradistinction  to  rachitis  there  is  here  an 
inflammatory  process,  accompanied  by  decalcification  and 
dilatation  of  the  Haversian  canals  and  medullary  spaces; 
the  calcified  bone-substance  containing  bone-cells  is  re- 
placed by  lamellar  connective  tissue,  hence  the  flexibility 
of  the  osteomalacic  pelvis  (osteitis  plus  osteoporosis). 

Characteristics. — As  the  bones  of  the  pelvis  begin  to 
soften,  the  transverse  diameter  is  diminished,  the  altera- 
tions beginning  in  the  anterior  pelvic  wall  in  response  to 
the  pressure  of  the  femora.  Later  the  characteristic 
alterations  just  described  for  the  pseudo-osteomalacic 
rachitic  pelvis  make  their  appearance,  and  the  most 
severe  grades  of  deformity  and  compression  result,  so 
that  even  digital  exploration  per  vaginam  becomes  im- 
possible on  account  of  the  approximation  of  the  tuberosi- 
ties of  the  ischium.  The  pubic  arch  disappears  or  as- 
sumes an  octagonal  shape.  The  central  portion  of  the 
sacrum  is  also  markedly  displaced  upward  and  backward, 
but — in  contradistinction  to  the  rachitic  pelvis  (cf.  Fig. 
141) — the  tip  of  the  coccyx  projects  forward  so  that  the 


224  DEFORMITIES  OF  THE  PELVIS. 

sacrococcygeal  curve  is  greatly  increased  and  the  outlet 
markedly  contracted  in  the  anteroposterior  diameter. 
The  iliac  bones  present  a  deep  furrow  running  from  the 
iliosacral  articulation  obliquely  upward  and  forward  to 
the  crest  or  to  the  anterior  spines  ("sulcus  iliacus'^). 
The  incomplete  fractures  which  are  frequently  seen  are 
due  to  softening  of  the  medullary  portion  of  the  bone, 
while  the  shell  remains  intact.  The  so-called  "  rubber 
pelves/^  finally,  are  absolutely  soft  and  yielding. 

Chai^acteristics. — The  course  of  labor  depends  solely  on 
the  degree  of  softening.  If  the  disease  has  been  cured  the 
pelvis  is  set  in  its  pathological  shape  and  spontaneous 
labor  is  impossible.  For  this  reason  a  careful  examina- 
tion should  be  made  during  pregnancy  to  determine 
whether  there  is  retroflexion  and  incarceration  of  the 
uterus  (see  §  15a  and  Figs.  102,  103,  105).  Acute  signs 
of  osteomalacia  must  be  looked  for,  such  as  pains  in  the 
bones  (beginning  in  the  horizontal  rami  of  the  pubis), 
muscular  cramps^  compressibility  of  the  bones  (beginning 
at  the  outlet),  and  especially  the  peculiar  waddling 
gait.  In  many  cases,  given  variously  as  from  17  to 
80  per  cent.,  spontaneous  labor  is  poss'ble  if  the  flexi- 
bility of  the  bones  is  such  as  to  permit  distention  of  the 
pelvic  canal  ;  if  not,  Cesarean  section  is  usually  the  only 
possible  procedure.  Whether  the  ovaries  should  be  re- 
moved or  a  complete  Porro  am])utation  performed  at 
the  same  time,  with  the  view  of  curing  the  disease,  is  still 
an  open  question  which  need  not  be  discussed  in  this 
place.  In  some  cases  the  induction  of  premature  labor 
might  be  considered. 

For  the  rest,  the  shape  and  size  of  the  interior  of  the 
pelvis  should  be  carefully  investigated. 

The  diagnosis  of  the  osteomalacic  pelvis  based  on  the 
presence  of  a  transverse  fold  in  the  skin  above  the  pelvis, 
the  beak-like  shape  and  upward  displacement  of  the  sym- 
physis, the  contraction  at  the  pelvic  outlet,  and  the 
diminution  in  the  intertrochanteric  distance  (see  §  3). 

Treatment. — During  labor  the  distention  of  the  "  lower 


FUNNEL-SHAPED  PELVES.  225 

uterine  segment ''  must  be  carefully  watched,  as  rupture 
is  very  apt  to  occur.  Excessive  distention  of  the  lower 
uterine  segment  is  a  contra-indication  for  version.  If  the 
pelvis  is  flexible  the  application  of  forceps  may  under 
favorable  conditions  be  considered.  Craniotomy  is  rarely 
called  for  ;  Cesarean  section  is  the  usual  procedure. 

Funnel=shaped  Pelves  (see  ^  20,  No.  11). 
(Figs.  51,  134-136,  138.) 

No.  5. — Funnel-shaped  pelvis,  generally  or  anteroposte- 
riorly  contracted  at  the  outlet. 

Etiology. — The  pelvic  outlet  may  be  contracted  in  gen- 
erally and  in  flat  contracted  pelves,  in  spondylolisthesis, 
osteomalacia,  and  in  bilateral  svnostosis  (cf.  Xos.  4,  66,  7, 
10). 

!N"o.  5a. — Infantile  or  undeveloped  pelvis  (Fig.  134). 

Etiology. — Arrest  of  development ;  abnormally  high 
position  of  tlie  promontory  witli  flattening  of  the  sacrum, 
perhaps  with  early,  although  not  necessarily  abnormal  ossi- 
fication, whereby  the  character  of  the  infantile  pelvis  is 
retained  and  the  weight  of  the  trunk  is  applied  more  pos- 
teriorly, so  that  transvere  enlargement  of  the  pelvis  be- 
comes impossible,  etc. ;  in  other  words,  an  accentuation 
of  the  infantile  properties. 

Characteristics. — Contraction  chiefly  and  most  fre- 
quently in  the  transverse  diameter  of  the  outlet  (Fig.  43, 
§  3);  then  in  the  conjugate  of  the  outlet;  frequently  all 
the  diameters  of  the  pelvic  outlet  are  diminished.  Mod- 
erate diminution  in  the  transverse  diameter^  of  the  outlet 
is  an  obstacle  to  labor  only  when  all  the  segments  forming 
the  outlet  are  contracted,  or  when  there  is  anterior  luxa- 
tion and  fixation  of  the  coccyx. 

The  rest  of  the  spinal  column  is  norn\al  ;  even  the  form 
and  position   of  the   sacrum  -  and  promontory  are  some- 

1 A  very  good  instrument  for  the  measurement  of  the  transverse  diam- 
eter of  the  outlet  has  been  devised  by  Klien  (Dresden). 

2  The  sacrum  is  long  and  narrow  and  usually  shows  only  a  slight  in- 
clination, but  this  is  not  due  to  an  increase  in  the  transverse  and 
decrease  in  the  longitudinal  curvature,  as  Schauta  found,  since  it  also 

15 


226  DEFORMITIES  OF  THE  PELVIS. 

times  quite  normal,  the  greatest  contraction  is  found  at 
the  outlet,  especially  in  the  transverse  diameter,  the  true 
pelvis  itself  being  rather  high. 

Influence  on  Pregnancy. — TJie  pelvic  inlet  being  normal, 
round,  or  oval,  with  the  long  axis  in  the  anteroposterior 
plane  and  only  a  slight  degree  of  contraction,  the  present- 
ing part  regularly  enters  the  true  pelvis  and  there  is  no 
tendency  to  uterine  displacements,  etc. 

Labor. — As  labor  progresses  the  presenting  part  meets 
with  serious  resistance,  for  it  cannot  move  in  any  direction. 
The  normal  rotation  into  the  anteroposterior  diameter 
takes  place  in  the  line  connecting  the  spines  of  the  ischium 
(§  7)  ;  the  shortening  of  this  line,  which  represents  the 
smallest  diameter,  and  of  the  distance  between  the  tuber- 
osities prevents  this  rotation.  The  head,  for  instance,  is 
arrested  with  the  sagittal  suture  in  the  oblique  or  in  the 
transverse  diameter,  i.  e.,  the  largest  diameter  of  the  head 
coincides  with  the  smallest  diameter  of  the  pelvis,  while 
the  occiput  often  slips  past  the  spine  of  the  ischium  into 
the  posterior  portion  of  the  excavation.  But  by  the  time 
the  head  has  reached  the  spines  of  the  ischium,  after  pass- 
ing through  the  pelvic  inlet,  the  greater  part  of  the  trunk 
has  escaped  from  the  fundus,  which  is  the  only  portion  of 
the  uterus  capable  of  contraction,  and  the  expulsive  forces 
come  to  a  standstill.  While  the  danger  of  rupture  from 
distention  of  the  lower  uterine  segment  is  slight,  pressure- 
necrosis  in  the  vagina  and  vesicovaginal  and  urethrovagi- 
nal fistulas  are  very  apt  to  result. 

Diagnosis. — The  transverse  diameter  of  the  outlet,  or, 
in  other  words,  of  the  plane  of  pelvic  contraction  and  the 

occurs  in  pelves  with  a  high  promontory  and  a  flat  sacruru.  In  such 
cases  it  is  due  to  the  greater  height  of  tlie  body  of  the  first  sacral  verte- 
bra over  the  ala,  thus  converting  the  transverse  diameter  into  two  lines 
running  downward.  The  pelvic  inlet  is  usually  round  with  a  tendency 
to  the  ovoid  shape,  the  result  of  the  anomalies  in  the  sacrum  ;  it  is 
higher  than  normal  and  more  concave  from  side  to  side,  while  the  in- 
sertion of  the  innominate  bones  is  situated  more  anteriorly.  The  in- 
clination of  the  pelvis  is  a  little  greater  than  normal,  the  symphysis 
somewhat  more  perpendicular — in  short,  the  pelvis  presents  infantile 
characteristics. 


FUNNEL-SHAPED  PELVES.  227 

conjugate  of  the  outlet,  are  found  to  be  diminished  (Fig. 
42,  §  3),  while  the  measurements  of  the  false  pelvis  are 
normal,  especially  those  of  the  pelvic  inlet.  The  tip  of  the 
coccyx  is  easily  ])alpated.  The  limits  which  permit  the 
delivery  of  a  full-grown,  vigorous  child  at  term  are  as 
follows  :  Distance  between  the  tuberosities  of  the  ischium 
3^  in.  (8  cm.  ;  normal :  about  4  in.  =  10  cm.)  if  the  other 
measurements  of  the  outlet  are  normal,  or  the  distance 
between  the  tuberosities  is  3|-  to  3f  in.  (3.5  to  9  cm.),  and 
the  distance  from  the  tuberosities  to  the  tip  of  the  coccyx 
only  2|-  in.  (7  cm. ;  nornial  :  3|-  in.  =  9.75  cm.),  or  the 
conjugate  of  the  plane  of  contraction  under  3f  in.  (9 
cm.;  normal:  4J  in.  =  11.5  cm.).  If  the  shape  and 
position  of  the  sacrum  are  normal  and  the  pelvic  outlet 
is  funnel-shaped,  we  have  to  deal  with  a  simple  infantile 
arrest  of  development. 

Treatment. — In  moderate  grades  of  contraction  inaction, 
and  later,  forceps.  If.  however,  the  distance  between  the 
tuberosities  is  3^  in.  (8  cm.),  or  the  conjugate  of  the  plane 
of  pelvic  contraction  under  3f  in.  (9  cm.),  craniotomy,  or, 
possiblv,  symphysiotomy  or  Cesarean  section,  is  the  only 
treatment.  Particular  care  is  necessary  in  the  use  of  the 
forceps,  on  account  of  the  great  danger  of  extensive  con- 
tusions or  of  separation  of  the  pelvic  joints.  If  the  dis- 
tance betAveen  the  tuberosity  and  the  tip  of  the  sacrum  is 
reduced  to  2|-  in.  (7  cm.)  the  forceps  may  be  employed 
onlv  when  the  distance  between  the  tuberosities  measures 
at  least  3f  in.  (8.5  cm.),  always  provided  that  we  are  deal- 
ing with  a  skull  of  normal  strength  belonging  to  a 
matured  fetus.  If  the  measurements  fjill  below  this  limit, 
and  a  living  child  is  desired,  sym])hysiotomy  or  Cesarean 
section  must  be  done  ;  the  former  operation  to  be  followed 
by  the  application  of  forceps  down  to  21  in.  (5.5  cm.)  as 
the  limit  for  the  distance  between  the  tuberosities.  A 
transverse  presentation  is  always  to  be  converted  into  a 
cephalic  presentation  ;  version  is  not  permissible.  The 
induction  of  premature  labor  in  the  thirty-fourth  week 
may  be  considered  if  the  distance  between  the  tuberosities 


228  DEFORMITIES  OF  THE  PELVIS. 

is  not  less  than  2|-  in.  (6.5  cm. — from  2J  to  2|-  in.  =  8 
cm.  to  6.5  cm.). 

No.  56. — Fetal,  undeveloped  decubital  pelvis  (Fig.  51). 

Etiologii. — Prolonged  confinement  in  bed  with  absolute 
inability  to  move  or  sit  up. 

Charadenstics. — The  spinal  column  is  almost  as  straight 
as  in  the  fetus,  so  that  the  sacrum  is  practically  the  con- 
tinuation of  the  axis  of  the  vertebral  column ;  the  prom- 
ontory is  high  and  projects  very  little.  The  inclination 
of  the  pelvis  is  considerable,  although  the  physiological 
anteflexion  does  not  take  place ;  on  the  other  hand,  the 
rotation  described  in  §  4,  No.  2,  does  not  take  place  either, 
and  thus  the  anterior  pelvis  is  not  elevated. 

There  is  no  transverse  expansion  and  the  sacrum  re- 
mains narroAV  and  straight,  the  iliac  bones  continue  flat 
and  small.  The  pelvic  inlet  is  round  or  ovoid  and  the 
true  pelvis  distinctly  funnel-shaped.  The  genitalia  them- 
selves do  not  develop  and  there  is  no  record  of  a  woman 
with  such  a  pelvis  having  given  birth  to  a  child. 

No.  5c. — Lumbosacrokyphotic  funnel-shaped  pelvis  (Figs. 
135  and  136). 

Etiology. — Rachitis  or  caries  in  the  lumbosacral  or 
lumbodorsal  region. 

Characteristics. — The  kyphotic  lumbar  vertebrae  draw 
the  first  sacral  vertebra  backward  and  upward,  so  that  the 
promontory  is  flattened  and  displaced  upward.  In  order 
to  maintain  the  equilibrium  the  anterior  portion  of  the 
pelvis  has  to  be  raised  and  the  pelvic  inclination  is  there- 
fore diminished.  In  this  position  the  sacrum  does  not  sup- 
port the  weight  of  the  trunk  to  the  normal  extent  and  is, 
therefore,  unable  to  effect  transverse  expansion.  The  pos- 
terior superior  spines  become  approximated,  the  innomi- 
nate bones  are  flattened  because  the  iliosacral  ligaments 
are  relaxed  on  account  of  the  failure  of  the  sacruui  to 
descend  and  draw  them  forward.  On  the  other  hand,  the 
lower  arms  of  the  lever — the  iliac  and  ischiatic  bones- 
become  approximated  ;  i.  e.,  the  transverse  diameter  of 
the  outlet  is  shortened.  In  addition,  the  tip  of  the  coccyx 


FUNXEL-SHAPED  PELVES.  229 

is  rotated  forward  and  thus  tends  to  increase  the  contrac- 
tion at  the  outlet.  The  diminished  transverse  concavity, 
which  may  even  go  on  to  convexity  of  the  sacrum,  and 
the  ^vide  separation  of  the  iliac  bones  are  the  only  signs 
of  rachitis. 

Influence  on  Pregnancy. — There  is  a  tendency  to  pen- 
dulous abdomen  on  account  of  the  lordosis  of  the  upper 
portion  of  the  vertebral  column,  and  consequent  diminu- 
tion in  the  size  of  the  abdominal  cavity. 

Labor. — Longitudinal  position  of  the  fetus  is  the  rule, 
the  largest  diameter  of  the  presenting  part  usually  adapt- 
ing itself  to  the  oblique  diameter  of  the  pelvis. 

Course  and  treatment  are  the  same  as  for  infantile 
funnel-shaped  pelves. 

Diagnosis. — The  time  at  which  the  vertebral  disease 
occurred  is  ascertained  and  the  probable  influence  on  the 
development  of  the  pelvis  determined.  The  iliac  bones 
•  are  widely  separated,  the  symphysis  projects,  the  pelvic 
inclination  is  diminished.  The  pubic  arch  and  the  diam- 
eters of  the  outlet  are  contracted.  In  contradistinction 
to  spondylolisthesis  the  lateral  portions  of  the  iliopectineal 
line  is  easily  reached  with  the  palpating  finger,  while  the 
promontory  is  almost  or  quite  beyond  its  reach. 

No.  bd. — Pelvis  obtecta,  spondylolisthesis  in  the  lumbar 
reg'on. 

Etiology. — The  same  as  in  the  preceding,  but  the 
kyphosis  is  compensated  by  marked  lordosis  of  the  low- 
est lumbar  vertebrae. 

^  Characteristics. — The  kyphosis  is  compensated  imme- 
diately above  the  pelvic  inlet  by  the  projection  of  the 
lowest  lumbar  vertebrae,  thus  forming  a  pelvis  obtecta, 
resembling  the  spondylolisthetic  pelvis. 

The  influence  on  labor  is  the  same  as  in  the  preceding 
pelvis. 

No.  be. — Kyphoscoliotic  funnel-sliaped  pelvis. 

Etiology. — Eachitis. 

No.  bf. — Pelvis  icith  contracted  outlet  due  to  luxation 
and  anJcylosis  of  the  coccyx. 


230  DEFORMITIES  OF  THE  PELVIS. 

The  characteristiG  sign  is  the  involvement  of  the  sacrum 
in  the  kyphoscoliosis.  On  the  side  of  the  scoliosis  the 
pelvic  inclination  is  very  slight  (usually  the  left  side); 
on  the  other,  it  is  quite  marked.  This  oblique  distortion 
is  combined  with  the  funnel  shape  of  the  true  kyphotic 
pelvis.  At  the  outlet  the  distort  on  is  reversed.  (For 
further  description  see  under  scoliotic  obliquely  contracted 
pelvis,  No.  iki.) 

Obliquely  Contracted  Pelves. 

(Figs.  139-142.) 

No.  6. — Obliquely  distorted  or  contracted  pelvis. 

No.  6a. — Obliquely  contracted  pelvis  due  to  scoliosis  or 
lordoscoliosis  (Figs.  139  and  140). 

Etiology. — Rachitis.  The  "  non-rachitic "  acquired  form 
of  kyphoscoliosis  does  not  produce  any  alteration  in  the 
shape  of  the  pelvis.  The  weight  of  the  trunk  presses 
more  heavily  on  the  side  corresponding  to  the  scoliosis,  so 
that  the  ala  of  the  sacrum  on  that  side  is  pushed  inward. 
The  counter-pressure  of  the  femur  on  the  innominate  bone 
produces  an  oblique  distortion  of  the  opposite  lialf  of  the 
pelvis.  If  scoliosis  is  combined  with  kyphosis  a  torsion 
of  the  vertebrae  is  produced  in  a  direction  opposite  to  that 
of  the  scoliosis.  The  resulting  abnormal  pull  on  the  ilio- 
.sacral  ligaments  draws  the  venter  of  the  ilium  in  the  same 
direction.  This  traction,  combined  with  the  counter- 
pressure  of  the  femur,  pushes  the  ilium  and  the  entire 
half  of  the  pelvis  corresponding  to  the  scoliosis  upward, 
producing  a  vertical  position  of  the  pelvis  with  the  ante- 
rior margin  of  the  venter  of  the  ilium  nearer  the  median 
line. 

Characteristics. — The  oblique  distortion  takes  place 
either  in  the  direction  opposite  to  that  of  the  undeveloped 
ala ;  i.  e.,  in  the  sagittal  ])lane  of  the  last  lumbar  vertebra, 
or  in  the  direction  corresponding  to  the  diseased  hip-joint. 
The  lumbodorsal  scoliosis  is  compensated  by  the  oblique 
contraction  of  the  pelvis,  the  compensation  being  effected 


OBLIQUELY  CONTRACTED  PELVES.  231 

either  by  scoliosis  of  the  sacrum  alone  to  the  opposite 
side,  or  by  rotation  of  the  last  lumbar  vertebra.  In 
general,  the  direction  of  the  latter  indicates  the  direction 
of  the  oblique  contraction,  and  on  this  side  the  ala  of  the 
sacrum  will  be  found  imperfectly  developed  and  the  iliac 
bones  perpendicular  or  even  inclined  inward  ;  the  corre- 
sponding half  of  the  pelvis  is  higher  than  the  other  half 
and  the  curve  of  the  iliopectineal  line  is  diminished : 
hence,  1,  the  true  conjugate  is  shortened  ;  2,  the  distance 
between  the  alae  of  the  sacrum  is  diminished  on  the  same 
side ;  and,  3,  the  oblique  diameter  from  the  sacro-iliac 
articulation  on  the  same  side  is  lengthened.  The  tuberosity 
of  the  ischium  on  the  side  of  the  scoliosis  usually  projects 
outward,  so  that  the  transverse  diameter  of  the  pelvic 
outlet  is  increased  (Fig.  139).  For  the  rest,  we  have  all 
the  signs  of  the  rachitic  pelvis. 

The  diagnosis  is  based  on  the  general  signs  of  rachitis 
and  on  the  age  at  which  the  disease  first  made  its  appear- 
ance. The  pelvis  shows  all  the  general  characteristics  of 
rachitis,  and  the  oblique  contraction  is  determined  by 
palpation,  by  measuring  the  height  of  the  crests  in  relation 
to  the  costal  margin,  and  by  determining  the  degree  of 
torsion  of  the  vertebral  column.  If  the  obliquity  is  very 
marked,  it  will  show  itself  in  a  difference  between  the  two 
external  oblique  diameters  (§  3) ;  the  more  marked  these 
differences  are,  in  the  following  measurements  of  Xagele 
and  others,  the  more  certain  is  the  diagnosis  of  even  a 
mild  grade  of  oblique  contraction  ;  no  one  pair  of  oblique 
diameters  is  in  itself  sufficient  to  establish  the  diagnosis. 
The  first  four  give  the  most  reliable  results  both  in  the 
skeleton  and  in  the  living  subject  (author's  own  measure- 
ments) : 

(1)  The  external  diagonal  of  the  false  pelvis  =  9  in.  (22.5 
cm.)  on  the  average  in  viva. 

(2)  The  width  of  the  iliac  bone  (posterior  superior  spine 
to  anterior  superior  spine)  —  6|-  in.  (16.8  cm.)  on  the  aver- 
age in  viva. 

(3)  The  distance  between  the  anterior  superior  spine  to 


232  DEFORMITIES  OF  THE  PELVIS. 

the  spinous  process  of  the  fifth  lumbar  vertebra  =  7|-  in. 
(18.6  cm.)  on  the  average  in  viva. 

(4)  The  distance  between  the  posterior  superior  spine 
and  the  symphysis  =  7 J  in.  (18.5  cm.)  on  the  average  in 
viva. 

(5)  The  distance  between  the  posterior  superior  spine 
and  the  tuberosity  of  the  ischium  of  the  other  side  =  8J  in. 
(20.5  cm.)  on  the  average  in  viva. 

(6)  The  distance  between  the  anterior  superior  spine 
and  the  tuberosity  of  the  ischium  of  the  other  side  =  9^ 
in.  (23.8  cm.)  on  the  average  in  viva. 

(7)  Height  of  the  pelvis  (from  the  highest  point  of  the 
crest  to  the  tuberosity  of  the  ischium)  —  8|  in.  (21.8  cm.) 
on  the  average  in  viva. 

Influence  on  Pregnancy. — During  pregnancy  the  higher 
grades  of  contraction  produce  all  the  symptoms  observed 
— a  pronounced  flat  pelvis. 

Labor. — As  indicated  in  Fig.  140  and  described  under 
the  flat  non-rachitic  pelvis  (2a),  the  head  may  meet  with 
such  marked  resistance  in  the  flattened  half  of  the  pelvis, 
which  corresponds  to  the  side  of  the  scoliosis,  that  ^'  extra- 
median  engagement "  takes  place  and  the  other  half  of  the 
pelvis  only  is  used.  In  its  subsequent  course  the  head 
meets  with  the  same  resistance  as  in  the  generally  con- 
tracted pelvis:  the  suboccipitobregmatic  periphery  usually 
descends,  with  the  lesser  fontanel  low  down.  Contractions 
of  this  severity  are  very  unfavorable. 

Treatment. — At  first  expectant.  From  the  thirtieth 
week  of  pregnancy  on  the  head  should  be  firmly  pressed 
into  the  pelvic  inlet  for  one  and  one-half  minutes  every 
week. 

In  cases  of  marked  shortening  of  the  sacrocotyloid 
distance  no  attempt  should  be  made  to  rotate  the  head  so 
as  to  bring  the  sagittal  suture  into  the  larger  oblique 
diameter.  The  latter  is  parallel  with  the  flattened  ilio- 
pectineal  line  and  the  corresponding  half  of  the  pelvis  is 
often  so  contracted  that  it  cannot  accommodate  the  sinciput 
in   the  sacrocotyloid  distance,   whereas   both   transverse 


OBLIQUELY  CONTRACTED  PELVES.  233 

diameters  of  the  head  can  pass  if  tliey  lie  parallel  to  the 
flattened  iliopectineal  line  and  the  sagittal  suture  coincides 
with  the  shorter  oblique  diameter,  the  lesser  fontanel  sink- 
ing low  down  in  the  pelvis  (presentation  of  the  occiput). 

If  labor  cannot  be  terminated  spontaneously,  the  only 
possible  operations  are  craniotomy  and  Cesarean  section. 

No.  66. — Obliquely  contracted  pelvis  due  to  asymmetry 
of  the  sacrum  (so-called  secondary  synostotic  or  Nagele's 
pelvis),  Fig.  142. 

(The  asymmetrically  obliquely  contracted  assimilation- 
pelvis,  see  below,  under  ]S'o.  11.) 

Etiology. — Congenital  absence  of  one  sacral  ala  with 
displacement  of  the  innominate  bone  and,  usually,  anky- 
losis of  the  sacro-iliac  joint. 

There  are  no  remains  of  inflammation.  An  inflamma- 
tion is  not  followed  by  such  complete  disappearance  of  the 
bone,  and  after  ankylosis,  which  is  given  as  the  reason  for 
the  disappearance  of  the  bone,  there  can  be  no  displace- 
ment of  the  innominate  bone. 

The  iliopectineal  line  is  flattened  on  the  diseased  side, 
the  normal  curve  being  preserved  on  the  sound  side.  The 
flattening,  displacement,  and  synostosis  are  due  to  the 
pressure  of  the  femur  on  the  sound  side. 

Characteristics. — Complete  or  partial  absence  of  one 
sacral  ala  vrith,  usually,  synostosis  of  the  sacro-iliac 
articulation.  The  corresponding  innominate  bone  is  per- 
pendicular and  rotated  toward  the  median  line,  though  as 
a  whole  it  is  displaced  upward  and  backward  :  the  curve 
of  the  corresponding  iliopectineal  line  is  flattened  ;  the 
symphysis  is  displaced  to  the  other  side,  hence  the  sacro- 
cotyloid  distance  is  diminished  and  the  tuberosity  of  the 
ischium  is  displaced  upward  and  inward  or  backward. 
The  other  half  of  the  pelvis  is  well  developed.  The 
pelvic  walls  of  the  diseased  side  are  approximated  as  far 
as  the  outlet.  The  shape  is  an  oval  with  the  long  axis 
oblique,  and  retains  its  direction  throughout. 

Diagnosis. — By  exclusion  of  rachitic  and  other  inflam- 
matory bone  diseases.     The  difference  in  the  height  of 


234  DEFORMITIES  OF  THE  PELVIS. 

the  crests  on  the  two  sides  is  determined.  The  iliopec- 
tineal  line  most  be  palpated  with  great  care  and  the  dis- 
tances between  the  symphysis  and  the  synostosis  carefully 
measured  to  obtain  the  conjugate.  If  this  distance  is 
3|  in.  (8.5  cm.)  or  more,  premature  labor  may  be  induced. 
The  oblique  diameter  is  to  be  measured  as  in  the  last- 
mentioned  pelvis. 

Influence  on  Labor. — The  available  space  during  labor 
has  the  characteristics  of  a  generally  contracted  pelvis 
with  a  triangular  inlet,  the  conjugate  of  which  corresponds 
to  the  line  joining  the  symphysis  and  the  iliosacral  synos- 
tosis. The  head  is  therefore  in  extreme  flexion  and 
presents  with  the  occiput ;  if  the  sacrocotyloid  distance  is 
very  much  diminished  the  same  remarks  apply  as  in  the 
preceding  pelvis.  The  contraction  at  the  outlet  presents 
serious  difficulties  ;  even  in  vertex  presentations  the  prog- 
nosis is  unfavorable,  in  any  other  it  is  distinctly  bad. 

Treatment. — The  application  of  the  forceps  can  only  do 
harm  and  version  is  of  no  avail,  because  the  head  cannot 
pass.  The  choice,  therefore,  lies  between  the  induction 
of  premature  labor,  craniotomy,  and  Cesarean  section. 
(For  moderate  grades  of  contraction,  especially  at  the 
outlet,  see  Funnel-shaped  pelvis,  No.  ba.) 

No.  Qc. — Obliquely  contracted  'pelvis  due  to  primary  in- 
flammatory synostosis  of  one  sacro-iliac  joint. 

Etiology. — Caries.  The  synostosis  is  primary.  The 
shape  of  the  pelvis  depends  on  the  date  of  the  disease. 

Characteristics. — A  variety  of  forms  occur,  ranging 
from  the  highest  degree  of  asymmetry,  as  in  Nagele's 
congenital  obliquely  contracted  pelvis  (due  to  secondary 
synostosis),  to  a  perfectly  symmetrical  form,  and  includ- 
ing intermediate  varieties  due  to  disease  in  early  child- 
hood. 

The  diagnosis  is  based  on  the  history  of  former  in- 
flammatory process,  the  presence  of  scars,  and  the  ab- 
sence of  displacement  of  the  diseased  innominate  bone. 

No.  Qd. — Obliquely  contracted  pelvis  due  to  impaired 
function  of  the  hip-joint  (Fig.  141). 


OBLIQUELY  CONTRACTED  PELVES.  235 

Etiology. — Coxalgia  ;  unilateral  congenital  luxation  of 
the  femur;  early  amputation,  etc.;  comminuted  fracture 
of  one  innominate  bone  or  of  one  sacral  ala  (Fritsch). 

All  the  bony  parts  of  the  diseased  pelvic  half  from  the 
tuberos'ty  of  the  ischium  to  the  crest  undergo  atrophy. 
The  pelvis  becomes  perfectly  perpendicular  and  assumes 
the  characteristic  funnel  shape  (like  the  diseased  side  of 
a  synostotic  pelvis).  Owing  to  the  pressure  of  the  sound 
thigh  the  corresponding  half  of  the  pelvis  is  pushed  over 
toward  the  diseased  side,  so  that  the  sound  half  becomes 
flattened  ;  the  acetabulum  on  the  diseased  side  may  be 
perforated. 

In  the  rarer  form  of  simple  coxalgia  without  the  effects 
of  the  pressure  of  the  thighs  the  diseased  half  under- 
goes contraction  as  in  the  synostotic  pelvis,  the  sacral  ala 
becoming  atrophied,  whereas  in  the  former  variety  atrophy 
usually  but  not  always  occurs  on  the  sound  side,  so  that 
the  sacrum  is  rotated  on  its  longitudinal  axis. 

In  contradistinction  to  IS^agele's  pelvis  the  oblique  oval 
form  observed  at  the  inlet  does  not  maintain  the  same 
direction  as  the  outlet  is  approached,  because  the  ischi- 
atic  portion  on  the  sound  side  is  forced  outward,  or  be- 
cause the  forward  and  outward  displacement  of  both 
tuberosities  of  the  ischium  tends  to  diminish  the  contrac- 
tion toward  the  outlet. 

Influence  on  Labor. — Luxation  of  one  femur  (usually 
backward  and  upward)  produces  various  forms,  depending 
on  the  age  of  the  individual  and  use  of  the  legs. 

(ci)  Congenital  Luxation. — When  the  child  is  lying 
down  the  diseased  half  of  the  pelvis  atrophies ;  the  iliac 
bone  is  perpendicular  on  account  of  the  pressure  of  the 
thigh  against  its  outer  surface ;  the  tuberosity  of  the  is- 
chium is  drawn  up  by  the  muscles  attached  to  the  tro- 
chanter. The  child  sits  on  the  diseased  tuberosity  because 
it  is  the  higher  of  the  two,  and  this  leads  to  oblique  con- 
traction of  the  pelvis  in  favor  of  the  sound  side.  In 
walking  the  child  throws  its  weight  chiefly  on  the  sound 
thigh,   hence  the  pressure  is  now  applied  to  the  sound 


236  DEFORMITIES  OF  THE  PELVIS. 

side,  and  the  diseased  half  of  the  pelvis  becomes  the 
greater. 

(6)  Acquired  Luxation. — If  the  luxation  is  acquired 
during  childhood  and  the  legs  have  never  been  used,  the 
shape  of  the  pelvis  is  the  same  as  in  the  congenital  form 
before  the  child  has  begun  to  walk,  except  that  there  is 
less  atrophy. 

In  adults  who  have  not  walked  after  the  accident  the 
diseased  half  of  the  pelvis  becomes  expanded  by  the 
traction  of  the  iliofemoral  ligament  and  the  psoas  muscle. 

In  both  children  and  adults  who  have  walked  after  the 
accident  the  shape  is  the  same  as  in  congenital  luxation 
jplus  the  effect  of  walking,  but  there  is  less  atrophy  and 
the  displacement  of  the  diseased  side  is  less  marked. 

For  diagnosis  and  treatment,  see  previous  variety. 

Transversely  Contracted  Pelves. 

(Fig.  144.) 

[No.  7. — Transversely  contracted  pelvis. 

No.  7a. — Transversely  contracted  pelvis  due  to  absence 
of  both  sacral  alee,  Robert's  pelvis  (Fig.  144). 

(Other  varieties  of  transversely  contracted  pelvis  occur 
as  tlie  result  of  arrested  development,  such  as  the  antero- 
posteriorly  oval  —  funnel-shaped  —  pelvis  and  circular 
pelvis,  which  represent  intermediate  forms.) 

Etiology. — Arrested  development.  (In  birds,  bats,  etc., 
there  is  fusion  of  the  iliosacral  joints ;  the  form  is  similar 
to  the  pelvis  of  most  mammals.)  The  absence  of  centers 
of   ossification    is  primary,   the   synostosis  is  secondary. 

Characteristics. — Fusion  of  both  iliosacral  articulations 
with  consequent  enormous  diminution  of  the  transverse 
diameter.  Both  halves  of  the  pelvis  are  shaped  like  the 
diseased  half  of  a  Nagele's  pelvis,  the  characteristic  asym- 
metry of  which  is  sometimes  seen  in  intermediate  forms. 
The  iliac  bones  are  displaced  upward  and  backward. 

The  diagnosis  is  based  on  the  intertrochanteric  distance, 
the  beak-like  shape  of  the  symphysis,  and  the  enormous 


ANOMALIES  OF  THE  PELVIS.  237 

contraction  of  the  entire  cavity  of  the  true  pelvis  with 
backward  displacement  of  the  sacrum. 

Treatment. — Induction  of  abortion  or  Cesarean  section. 
The  OS  is  very  inaccessible  on  account  of  the  contraction 
of  the  true  pelvis. 

Xo.  76. — Transversely  contracted  pelves  due  to  primary 
inflammation  and  secondary  synostosis  of  both  iliosacral 
articulations. 

Etiology. — Caries.  (Until  the  fifth  year  of  life  the 
lateral  growth  of  the  sacral  alse  is  cartilaginous ;  the 
growth  is  not  completed  until   the  fourteenth  year.) 

Characteristics. — Analogous  to  the  form  described 
under  Obliquely  contracted  pelves,  Xo.  ^c,  except  that 
the  deformity  in  this  case  is  bilateral.  History  and  evi- 
dences of  an  inflammatory  process  in  childhood.  Even 
the  milder  grades  are  funnel-shaped. 


Anomalies  of  the  Pelvis  due  to  Congenital  or  Early  Acquired 

Defects. 

(Figs.  145-147.) 

Xo.  8. — Luxation  of  both  femora  (Fig.  145),  club-foot, 
absence  of  the  lower  extremities,  etc. 

The  ^^ decubital''  pelvis  (Fig.  51)  is  described  under 
the  head  of  Fetal  undeveloped  pelvis,  Xo.  56. 

The  ^' sitz-pelvis"  is  contracted  in  its  anteroposterior, 
and  expanded  in  its  transverse  diameter,  like  the  pelvis 
in  luxation  of  both  femora. 

The  club-foot  pelvis  is  contracted  transverselv  (Fig. 
146). 

Etiology. — Congenital  or  due  to  traumatism  in  early 
infancy. 

Congenital. — (a)  Development  of  the  head  of  the  femur 
in  an  abnormal  situation  high  up  on  the  iliac  bone,  with- 
out the  formation  of  an  acetabulum  ;  (6)  the  same,  but 
with  the  formation  of  an  acetabulum. 

Conjugate  rarely  under  3^  in.  (9  cm.),  usually  between 
Z\  and  4  in.  (9  and  10  cm.). 


238  DEFORMITIES  OF  THE  PELVIS. 

Talipes  varus  on  both  sides.  The  leg  is  moved  as  if  it 
were  rigid ;  posterior  displacement  of  acetabulum  and 
tuber  ischii.     Marked  pelvic  inclination. 

CharacteristiGs. — As  the  center  of  gravity  is  displaced 
backward  the  lumbosacral  portion  and  the  sacrum  are 
forced  downward  between  the  innominate  bones  either  in 
front  or  behind  :  the  promontory  and  tip  of  the  coccyx 
project,  while  the  central  portion  of  the  sacrum  recedes. 
The  transverse  diameter  as  well  as  the  inclination  of  the 
entire  pelvis  is  increased^  while  the  true  conjugate  is 
diminished  ;  the  iliac  bones  are  perpendicular. 

Diagnosis. — Waddling  gait,  pendulous  abdomen  due  to 
the  lumbar  lordosis  and  shortening  of  the  true  conjugate  ; 
the  pelvis  is  very  wide  ;  the  trochanters  come  in  relation 
with  the  outer  surface  of  the  iliac  bones  so  that  they  are 
not  touched  by  Nekton's  line  (anterior  superior  spine  to 
tuberosity  of  the  ischium) ;  the  thighs  are  adducted  and 
rotated  inward.  The  differential  diagnosis  from  spondy- 
lolisthesis is  based  chiefly  on  accurate  measurements  and 
the  relation  to  Nekton's  line. 

Influence  on  Pregnancy. — Pendulous  abdomen. 

Labor. — The  indications  for  operative  interference  are 
the  same  as  in  the  flat  pelvis.  At  first  inaction,  as  the 
great  transverse  expansion  and  shallowness  of  the  pelvis 
often  lead  to  precipitate  delivery.  Operations  are  diffi- 
cult to  perform  on  account  of  the  extreme  adduction  of 
the  thighs. 

Double  talipes.  As  a  result  of  the  backward  displace- 
ment of  the  acetabulum  and  tuberosity  (see  Etiology)  the 
pelvic  inclination  is  markedly  increased,  the  promontory 
is  low  and  prominent,  and  the  entire  pelvis  nuich  con- 
tracted in  its  transverse  diameter.  When  both  legs  are 
wanting  ("  Sitzbecken  "),  the  shnpe  of  the  pelvis  is  the 
same  as  in  double  luxation  :  lengthening  of  the  transverse 
diameter  with  approximation  of  the  crests ;  marked  flat- 
tening. 

No.  9. — Split  pelvis,  pelvis  fissa  (Fig.  147). 

Etiology. — Congenital  failure  of  union  between  the  two 


SPONDYLOLISTHETIC  PELVES.  239 

halves  of  the  pelvis,  almost  always  associated  with  ex- 
stropiiy  of  the  bladder.  The  weight  of  the  trunk  plus 
the  pressure  of  the  thighs  produce  marked  rachitic  charac- 
ters. 

Characteristics. — In  the  fetus  the  gap  in  the  symphysis 
measures  from  1 J  to  2 J-  in.  (3  to  6  cm.)  ;  in  the  adult, 
from  3^  to  6  in.  (8  to  15  cm.).  Marked  increase  in  the 
transverse  diameter  at  every  point;  the  sacrum  falls  for- 
ward ;  the  distance  between  the  anterior  superior  spines  is 
increased,  that  between  the  posterior  superior  spines  is 
diminished.  In  rare  cases  synostosis  of  the  iliosacral 
articulation  is  present,  thus  permitting  function.  The 
distance  between  the  thighs  is  markedly  increased. 

The  influence  on  labor  is  the  same  as  in  the  justomajor 
pelvis.  After  labor  prolapse  of  the  uterus  occurs  regu- 
larly, otherwise  the  deformity  occasions  no  obstetrical 
difiiculties. 

Spondylolisthetic  Pelves. 

No.  10. — Spondylolisthetic  pelvis  (Fig.  143). 

Four  grades  are  distinguished  :  (1)  The  fifth  lumbar 
vertebra  projects  over  the  base  of  the  sacrum  ;  (2)  It  pro- 
jects over  the  pelvic  inlet;  (3)  It  slips  into  the  pelvic 
inlet ;  (4)  It  lies  completely  within  the  true  pelvis.  The 
latter  variety  may  lead  to  fracture. 

Etiology. — External  injury  and  inflammatory  processes. 
The  interarticular  portion  is  elongated  ;  it  represents  the 
line  of  fusion  of  the  anterior  and  posterior  centers  of 
ossification  in  the  fetus.  If  fusion  fails  to  take  place 
fixation  is  eflected  by  ligamentous  masses  (sjwiuJyloh/sis 
inter  articular  is),  Avhich  predisposes  to  later  spondylolis- 
thesis. 

Characteristics. — Contraction  of  the  pelvic  inlet  due 
to  the  anterior  dislocation  of  the  body  of  the  fifth  lumbar 
vertebra.  Lordosis  of  the  lumbar  portion  is  produced, 
so  that  the  central  vertebrse  are  on  a  level  with  the  sym- 
physis, wliich  is  higher  than  normal,  while  the  upper 
portion  of  the  sacrum   is  displaced   backward   and   the 


240  DEFORMITIES  OF  THE  PELVIS, 

lower  portion  forward,  as  in  the  funnel-shaped  pelvis.  On 
these  factors  depends  the  degree  of  contraction. 

The  lateral  interarticular  portions  of  the  last  lumbar  ver- 
tebra become  elongated  (cf.  Fig.  143)  and  thus  give  sup- 
port to  the  spondylolisthetic  vertebral  column.  Synostosis 
takes  place  between  the  bodies  of  the  vertebrae. 

The  pelvic  inclination  is  practically  obliterated  ;  the 
transverse  diameter  of  the  false  pelvis  is  increased,  while 
the  pelvic  inlet  is  slightly,  and  the  outlet  markedly,  con- 
tracted.   The  anteroposterior  diameters  are  all  diminished. 

Influence  on  Pregnancy  and  Labor. — Pendulous  abdo- 
men. Tendency  to  transverse  positions.  If  the  pelvic  incli- 
nation is  slight,  marked  lordosis  of  the  lumbar  spine  exerts 
an  unfavorable  influence  on  labor;  the  head  in  its  descent  is 
unable  to  adapt  itself  to  the  sudden  increase  in  the 
angle  of  the  pelvic  cavity.  The  degree  of  contraction 
may  be  so  slight  that  labor  may  be  terminated  spon- 
taneously, or  Cesarean  section  may  be  required. 

Diagnosis. — There  is  a  history  of  injury  in  childhood. 
Lumbar  lordosis  and  prominence  of  the  hips  laterally  ;  the 
thorax  reaches  almost  to  the  pelvis  and  transverse  folds 
of  skin  are  seen.  The  conjugatosymphyseal  angle  is 
diminished  and  the  rima  pudendi  is  placed  too  far  for- 
ward. The  presence  of  the  spondylolisthetic  angulation 
is  most  easily  detected  by  palpation,  beginning  at  the 
lumbar  portion  and  going  down,  and  the  marked  gib- 
bosity between  the  kyphotic  sacrum  and  the  lordosed 
lumbar  spine  affords  an  important  diagnostic  point  to  dis- 
tinguish this  variety  from  the  rachitic  and  from  the 
lumbosacrokyphotic  pelvis. 

Treatment. — A  conjugata  pseudovera  of  2|  in.  (6  cm.) 
is  an  absolute  indication  for  Cesarean  section  ;  from  2| 
to  3  in.  (6  to  7.5  cm.)  for  craniotomy  or  Cesarean  section ; 
from  2|-  to  3J-  in.  (7  to  8  cm.)  for  induction  of  premature 
labor  between  the  thirty-second  and  thirty-sixth  weeks  ; 
from  3^  to  3f  in.  (8  to  9  cm.)  for  expectant  treatment. 

Podalic  version  should  never  be  employed  (see  Funnel- 
shaped  pelves,  No.  5a). 


ASSIMILA  TION-PEL  VES.  241 

AssiiiiiIation=pelves  with  so=calIed   *♦  Intercalated  " 

Vertebra. 

No.  11. — Assimilation-pelvis  with  intercalated  vertebra 
(properly  called  transitional  vertebra). 

No.  11a. — Asymmetrical  assimilation-pelvis  (Fig.  137). 

Etiology. — Hereditary  arrest  of  development  or  imper- 
fect development.  Either  the  twenty-fifth  vertebra  has 
not  assnmed  its  sacral  character  on  both  sides  or  the 
twenty-fourth  vertebra  partially  partakes  of  the  sacral 

type. 

Characteristics. — On  one  side  there  is  complete  absence 
of  the  ala,  on  the  other  side  the  transverse  process  of 
the  lumbar  vertebra  is  preserved.  Thus,  the  imperfectly 
developed  vertebra  is  not  properly  supported  and  de- 
scends. Lumbar  scoliosis  results  and,  finally,  oblique 
contraction  of  the  pelvis  toward  the  opposite  side  is 
superadded.  When  combined  with  rachitis  these  pecu- 
liarities are  very  marked.  The  oblique  contraction  does 
not  take  place  when  the  articular  surface  of  the  lower 
vertebra  projects  upward  and  thus  supports  the  imperfect 
upper  half  of  the  vertebra. 

No.  116. — Symmetrical  assimilation-pelvis  (Fig.  135). 

Etiology. — The  same  as  in  the  last  variety,  except  that 
either  the  twenty-fourth  vertebra  has  developed  with  a 
sacral  vertebra — upper  assimilation  ;  or  the  thirtieth  ver- 
tebra has  done  so — lower  assimilation. 

Characteristics. — In  upper  assimilation,  where  the 
entire  twenty-fourth  vertebra  forms  part  of  the  sacrum, 
the  promontory  is  high  ;  the  intervertebral  disk  between 
the  first  and  second  vertebrae  persists,  and  the  angle  of 
the  promontory  is  very  little  developed.  As  a  result  the 
curvature  of  the  lumbar  portion  is  diminished  and  the 
center  of  gravity  is  displaced  forward  ;  compensation  is 
effected  by  diminution  in  the  pelvic  angle  and  slight 
anterior  inclination  of  the  upper  portion  of  the  body. 
The  transverse  diameter  is  diminished  and  the  pelvis 
assumes  the  funnel  shape  characteristic  of  the  kyphotic 
pelvis. 

16 


242  DEFORMITIES  OF  THE  PELVIS. 

There  are  cases  of  true  supernumerary  vertebrae  in  the 
form  of  arches  without  bodies,  since  the  latter  are  derived 
from  the  arch  (Gegenbauer,  Rosenberg). 

Anomalies  of  the  Pelvis  due  to  Bone=tumors  and  Exostoses 
the  Result  of  Fractures. 

(Figs.  148-150.) 

No.  12. — Acanthopelys  (Fig.  148). 

Often  seen  in  rachitic  individuals.  Ossification  of  the 
ecchondroses  which  normally  form  as  the  individual  de- 
velops (Virchow). 

The  spiny  exostoses  are  seen  at  the  symphysis,  the 
iliopubic  tubercle  (acetabulum),  the  sacro-iliac  synarthro- 
sis, and  the  promontory. 

They  often  lead  to  necroses  and  to  rupture  of  the 
uterus. 

No.  13. — Tumors  of  the  pelvie  bones. 

No.  13a. — Encliondroma  (Fig.  150). 

Heteroplastic,  hence  first  formed  from  pre-existing 
cartilage  (Virchow).  They  show  a  tendency  to  ossifi- 
cation. 

They  usually  grow  from  the  posterior  wall  of  the  pelvis 
and  fill  almost  the  entire  excavation,  like  fibromata. 

Cesarean  section  is  usually  required. 

No.  136. — Fibroma,  rarely  as  large  as  the  last-men- 
tioned tumor. 

No.  13c. — Sarcoma.  The  most  frequent  varieties  are 
round-celled,  spindle-celled,  and  soft  medullary  sarcomata. 

They  are  usually  very  large  and  grow  from  the  pos- 
terior wall. 

No.  13(i. — Cysts.  Combined  with  sarcoma  or  enclion- 
droma. 

No.  13e. — Carcinoma.  Metastatic.  Rarely  of  large 
size ;  it  leads  to  osteoporosis,  hence  the  bones  are  soft. 

No.  13/. — HydrorrhacMs.  Due  to  failure  of  union. 
Secondary  unilateral  scoliosis  and  asymmetry.  The  sac 
should  not  be  disturbed. 

No.  14. — Fractures  (Fig.  149)  of  the  sacrum,  ramus  of 


LACERATIONS  OF  GENITALIA  DURING  LABOR.    243 

the  ilium,  of  the  acetabulum,   with   or   without   callus- 

exostoses,  aiul   with   or  without  oblique  contraction   (in 

Fritsch's  case  contraction  was  due  to  fracture  of  the  right 

ala). 

Generally  Enlarged  Pelves. 

No.  15a. —  Generally  enlarged  (justomaj or)  pelves. 

Abnormal  development,  in  women  either  of  gigantic 
stature  or  of  ordinary  height. 

The  increase  in  the  various  diameters  rarely  exceeds  |- 
in.  (2  cm.).  The  enlargement  is  greatest  in  the  antero- 
posterior direction. 

No.  156. — Funnel-shaped  enlarged  pelvis. 

Abnormal  development.  The  outlet  is  normal,  the  inlet 
only  being  enlarged. 

No.  15c. — Enlarged  pelvis  due  to  flattening  of  the  iliaG 
bones. 

Abnormal  development.  Instead  of  130  to  140  degrees, 
as  in  the  normal  female  pelvis  (150  to  160  degrees  in  the 
male),  the  angle  formed  by  the  iliac  bone  with  the  lateral 
wall  of  the  true  pelvis  is  1 05  degrees. 

Influence  on  Labor. — Premature  engagement  of  the 
head  in  the  superior  strait  and  rapid,  or  even  precipitate, 
delivery  if  the  labor-pains  and  the  contractions  of  the 
abdominal  muscles  are  vigorous.  The  head  fails  to  per- 
form the  regular  rotatory  movements ;  the  occiput  may 
descend  into  the  hollow  of  the  sacrum  or  the  anterior 
fontanel  may  present. 


CHAPTER   YII. 
PATHOLOGY   OF    LABOR. 

^20.  LACERATIONS  OF  THE  GENITALIA  DURING  LABOR. 

(«)  Rupture  of  the  Uterus. — Pupture  during  pregnancy, 
especially  if  attended  with  marked  septic  phenomena, 
always  raises  a  suspicion  of  criminal  abortion.     A  rap- 


244  PATHOLOGY  OF  LABOR. 

Fig.  151.  Child  from  an  Oblique  Presentation,  Position  with  the  Body 
Doubled  on  Itself,  "  Conduplicato  Corpore  "  (neglected  transverse  posi- 
tion).— Labor  was  impossible;  the  child  died.  Arm  and  shoulder  pro- 
lapsed and  were  markedly  edematous  and  excoriated  (original  water-color 
from  a  preparation  in  the  Heidelberg  Gynecological  Clinic). 

tured  rudimentary  horn  or  tubal  sac  has  often  been  mis- 
taken for  the  rupture  of  a  normally  formed  uterus. 
Spontaneous  ruptures  occur  after  Cesarean  section,  the 
uterus  giving  way  at  the  site  of  the  scar  (see  §  14,  under 
Traumatism  ;  §  15,  16  ;  §  17).  Injuries  during  labor  are 
divided  according  to  their  etiology  as  follows  : 

(a)  Lacerations ;  (b)  erosions,  either  («)  incomplete,  or 
(j9)  complete  or  perforating,  with  or  without  total  escape 
of  the  ovum  into  the  abdominal  cavity. 

Lacerations  are  also  divided  according  to  their  seat  into: 
(1)  rupture  of  the  fundus  ;  (2)  transverse  rupture  going  on 
to  total  separation  of  the  body  of  the  uterus  from  the  vagina; 
(3)  simple  lacerations  of  the  cervix  ;  (4)  lacerations  of  the 
cervix  with  solution  of  continuity  in  the  vaginal  vault, 
especially  dangerous  on  account  of  infection. 

The  normal  uterus  in  labor  consists  of  the  contracting 
muscular  layer  of  the  body  which  gradually  diminishes  in 
thickness  as  the  cervix  is  approached,  and  in  some  cases, 
especially  when  the  labor-pains  are  abnormally  severe, 
ends  abruptly  at  the  contraction-ring,  and  of  the  distended 
"^  lower  uterine  segment,^^  which  includes  the  lower  portion 
of  the  body  of  the  uterus  as  far  as  its  attachment  to  the 
peritoneum  and  the  cervix  (cf.  §  6). 

Below  the  uterus  is  fixed  by  the  unyielding  connective 
tissue  of  the  lower  portion  of  the  cervix  and  of  the  vagi- 
nal vault  and  by  the  retractores  uteri  muscles,  as  described 
in  §  6.  Additional  fixation  is  usually  effected  by  the 
OS  becoming  wedged  in  between  the  head  and  the  pelvic 
wall.  The  resistance  is  supplied  by  the  advancing  body 
of  the  child  as  it  passes  through  the  inlet,  the  external  os 
being  fully  dilated.  The  tears  which  are  thus  produced 
have  been  described  in  §  G  and  illustrated  in  Figs.  16  and 
17  in  the  text  and  on  Plate  34,  all  taken  from  original 


LACERATIOXS  OF  GENITALIA  DURING  LABOR.     245 

preparations.  The  excessive  longitudinal  distention  be- 
comes complicated  by  the  pressure  of  the  head  against  the 
pelvic  wall.  Hence  we  may  have  rupture  even  in  the 
absence  of  pelvic  contraction  in  hydrocephalus  (Figs.  133, 
133(7,  152,  153,  and  157),  or  in  oblique  positions  of  the 
fetus  (see  Fig.  98  and  in  the  author's  Atlas  of  Labor  and 
Operative  Obstetrics),  especially  in  spontaneous  develop- 
ment and  in  partus  conduplicato  corpore  {Ibid,  and  Fig. 
151).  The  contraction-ring  recedes  to  the  level  of  the 
navel,  while  the  lower  uterine  segment  becomes  excessively 
distended.  Thus  the  child's  trunk  is  forced  into  the  lower 
uterine  segment  and  the  latter  begins  to  bulge.  This  is 
the  time  of  greatest  danger.  The  contracting  fundus  is 
held  fast  by  the  round  ligaments,  v>diich  are  stretched  to 
their  utmost.  If  the  abdominal  pressure  is  not  sufficient 
to  force  the  head  into  the  true  pelvis  it  becomes  danger- 
ous because  it  acts  throuo^h  the  bodv  of  the  fetus  on  the 
lower  portion  of  the  uterine  wall,  which  is  already  sub- 
jected to  excessive  pressure.  The  nerve-centers  in  this 
region  are  st'mulated  by  this  excessive  pressure  (§  5)  and 
thus  give  rise  to  renewed  labor-pains  and  abdominal 
pressure.  The  fetal  axis-pressure  described  in  §  5  indi- 
cates the  probable  seat  of  the  rupture.  This  pressure 
is  increased  even  more  by  the  introduction  of  the  hand 
(violent  rupture,  rupture  due  to  external  violence),  hence 
longitudinal  tears  occur  most  frequently  in  the  lateral 
portion  of  the  uterus. 

The  tear  begins  as  a  subperitoneal  hematoma,  the  blood 
collecting  between  the  separated  muscle-fibers.  There 
may  be  extensive  separation  of  the  peritoneum  without 
complete  or  perforating  laceration  necessarily  resulting ; 
in  Figs.  152  and  153  the  remains  of  the  original  hematoma 
are  seen. 

Rupture  of  the  anterior  or  posterior  wall  is  less  fre- 
quent, but,  according  to  my  collection  of  "  one  hundi'ed 
and  one  complete  ruptures  with  complete  escape  of  the 
child  into  the  abdominal  cavity,"  appears  to  occur  most 
frequently  as  a  result  of  violent  traumatism.     Rupture 


246 


PATHOLOGY  OF  LABOR. 


of  the  fundus  (Fig.  18  in  the  text),  which  by  itself  is 
exceedingly  rare,  was  also  observed  to  follow  traumatism, 
as  in  tlie  above-mentioned  case  of  Simpson's,  in  which 
there  was  said  to  be  fatty  degeneration  of  the  muscular 
layer,  although  the  specimen  was  not  examined  until  the 
third   day  of  the  puerperium.     After  the  escape  of  the 


Fig.  16. — Funnel-shaped  complete  rupture  of  the  uterus  (Ru.),  extend- 
iiioj  from  the  contractiou-ring  {C.R.)  to  within  an  inch  of  the  external  os 
{A. Mm.).  This  line  corresponds  to  the  posterior  peritoneal  attachment 
and  to  the  insertion  of  the  retractores  uteri.  Unt.,  Ut.,  S.,  lower  uterine 
segment ;  PL,  placental  site. 


ovum  the  amniotic  sac  may  be  completely  preserved, 
especially  if  the  rupture  is  due  to  the  giving  way  of  an 
old  Cesarean-section  scar  ;  but  more  frequently  the  am- 
niotic fluid  is  discharged  into  tlie  abdominal  cavity,  an 
accident  which   does   not   necessarily  lead   to   infection. 


LACERATIONS  OF  GENITALIA  DURING  LABOR.    247 


The  most  dangerous  are  transverse  ruptures  and  those 
which  open  the  vaginal  vault. 

From  a  diagnostic  point  of  view,  therefore,  it  is  of 
the  greatest  importance  to  determine  the  moment  when 
excessive  distention  of  the  lower  uterine  segment  begins. 
The  contraction-ring  is  high  (that  is,  more  than  a  hand^s 


Fig.  17. — This  rupture  is  analogous  to  that  seen  on  Plate  34,  except  that 
it  includes  the  lip  of  the  external  os.  Both  forms  of  rupture  are  particu- 
larly dangerous  because  the  infectious  germs  in  the  vagina  are  able  to 
make  their  way  into  the  peritoneal  cavity.  Letters  as  in  Fig.  16  (original 
drawings  from  preparations  in  the  Munich  Gynecological  Clinic). 

breadth  above  the  symphysis,  or  even  as  high  as  the 
umbilicus).  The  head  fails  to  engage  in  the  true  pelvis, 
the  lower  uterine  segment  causes  the  abdominal  walls  to 
bulge,  simulating  an  overfilled  bladder.  The  lower 
uterine  segment  as  well  as  the  round  ligament  are  tense. 
The  fundus  is  very  small  and  hard  and  no  fetal  portions 


248 


PATHOLOGY  OF  LABOR. 


can  be  palpated.     Labor-pains  follow  each  other  in  rapid 

succession  ;  pulse  and  respiration  are  greatly  accelerated. 

If  the  woman  suddenly  goes  into  collapse,  labor-pains 

cease,  and  blood  is  discharged  from  the  vagina,  Ave  know 


3/ 


<ly   J:  AMr?v:\ 


^ 


Fig.  18.— Eupture  of  the  fundus  with  the  fetus  in  situ;  laceration   at 

the  external  os. 

that  rupture  has  taken  place.  The  accident  can  be 
diagnosed  from  the  outside  ;  it  is  not  necessary  to  intro- 
duce the  hand  for  the  purpose  of  making  an  exploration. 


LACERATIONS  OF  GENITALIA  DURING  LABOR.    249 

as  it  only  gives  the  woman  pain  and  tends  to  increase  the 
danger  of  sepsis.     The  various  parts  of  the  fetal  body  can 
be  distinctly  felt  through  the  abdominal  walls  and  in  some 
cases   can   even  be  seen.     The  presenting  part,  head  or 
shoulder,  is  found  to  have  receded  from  the  pelvic  inlet. 
Treatment. — If  rupture  is  imminent  the  w^oman  should 
be   delivered    immediately ;    unless   Cesarean    section    is 
absolutely   indicated    it    should    not    be   attempted,^  on 
account  of  the  delay  of  the  necessary  preparation  if  it  is 
to   be  performed    according   to   the    rules    of  antisepsis. 
Hence,  perforation,  craniotomy,  embryotomy,  or  decapi- 
tation should   be  performed.     Version   should  never  be 
attempted.     On  no  account  should  the  woman  be  allowed 
to  exert  abdominal  pressure.     An  anesthetic  should  be 
given,  and    if  the  child   is   alive   and    the   presentation 
favorable  the  woman  should  be  put  into  Walcher's  posi- 
tion after  the  labor-pains  have  subsided.     If  rupture  has 
already  taken  place  the  child  should  be  at  once  extracted 
per  vias  naturales.     If  the  child  has  been  completely  dis- 
charged  into  the  abdominal  cavity  the  same  procedure 
should  be  attempted.     I  think  I  have  attained  my  object 
of  pleading  in  favor  of  celiotomy  by  the  collection  of  one 
hundred  cases  ^   of  this  kind,  and  'l  shall  adhere  to  my 
view  until  the  publication  of  a  new  series  of  at  least  a 
dozen  cases  of  delivery  per  vias  naturales  convinces  me 
that  better  results  are  obtained  in  that  way  ;  they  were 
certainly  worse  In  pre-antiseptic  times.     In  any  case  of 
this  kind  the  decision  always  depends  upon  whether  in- 
fection of  the  peritoneum  has  occurred  or  not.     Celiotomy 
enables  us  to  control  the  hemorrhage  and  to  repair  the 
rupture  in  the  uterus  properly,  but  it  also  adds  the  danger 
incident  to  the  entrance  of  air,  to  the  irritation  of  the 
intestines  with  hands  and    sponges,  and    to    the  caustic 
effect  of  antiseptic  fluids.     These  things  must  be  avoided 
as  much  as  possible.     If  infection  has  already  taken  place 
it   cannot  be  removed,   and  the  least  excoriation  of  the 
endothelium  on  the  peritoneum  permits  its  entrance  into 

1  Miinch.  med.  Woch.,  1889,  and  Inaugural  Dissert.,  Munich,  1886. 


250  PATHOLOGY  OF  LABOR. 

Fig.  152.  Complete  Rupture  of  the  Uterus  ;  one  arm  is  protruded  into 
the  abdominal  cavity;  due  to  brow  presentation  of  a  hydrocephalic  fetus 
in  contracted  pelvis  (see  Figs.  133,  133a). — Abnormal  anterior  rotation 
of  the  right  coruu  of  the  uterus  ;  the  round  ligament  on  the  right  side 
and  the  corresponding  tube  are  visible  (they  were  palpable  before) ;  the 
bluish  color  indicates  the  limits  of  the  subperitoneal  hematoma  in  the 
broad  ligament  and  in  the  perimetrium. 

Fig.  153.  The  ruptured  uterus  of  the  same  case  (Fig.  152).  (Both 
original  water-colors  from  a  case  in  the  Heidelberg  Obstetrical  Poli- 
klinik). — At  the  fundus  the  fold  in  the  perimetrium  due  to  the  con- 
tractions is  readily  recognized.  The  placenta  and  fetal  membranes  are 
in  the  fundus  uteri.  The  umbilical  cord  passes  through  the  iutact 
cervical  canal  into  the  vagina.  The  rupture  is  on  the  right  side.  The 
intraligamentary  connective  tissue  was  the  first  to  give  way,  the  result- 
ing hemorrhage  (the  cruor  of  which  is  visible)  separating  the  serosa 
until  it  ruptured.  The  separation  of  the  perimetrium  can  be  plainly 
seen  in  the  upper  part  of  the  picture. 

the  peritoneal  cavity.  If  this  accident  is  avoided  celiot- 
omy itself  appears  to  have  a  favorable  effect,  as  in 
tuberculous  peritonitis.  This  has  been  proven  experi- 
mentally and  bacteriologically  by  Barbacci  ^  and  others ; 
clinically  by  Fritsch,  v.  Winckel,  etc. 

Drainage  of  Douglas'  pouch  with  iodoform  gauze  and 
drainage-tube,  combined  with  compression  of  the  abdomen, 
is  applicable  in  most  cases ;  in  others  it  will  be  better  to 
drain  by  means  of  a  strip  of  gauze  inserted  into  the  lower 
angle  of  the  wound. 

If  it  is  probable  that  infection  has  not  taken  place  the 
question  of  suturing  a  smooth  rupture  might  be  con- 
sidered. 

In  a  case  of  fibrinous  peritonitis  the  author  once  performed  a 
successful  Porro  amputation  twenty-seven  hours  after  complete 
rupture  with  escape  of  the  head  into  the  region  of  the  liver.  The 
pedicle  and  Douglas'  pouch  were  covered  with  iodoform  gauze 
which  was  passed  out  through  the  cervix. 

Opening  of  the  vaginal  vault  in  combination  with 
celiotomy  always  terminates  fatally.  There  is  one  case 
reported  by  Leopold  in  which  a  cure  was  effected  by 
means  of  a  Porro  amputation.     The  proportion  of  re- 

iSee  abstract  of  mine  in  Centralbl.  f.  Gyn.,  about  the  end  of  1893. 


Tab.  68. 


t 


"^- 


Fig.  152 


Tf 


Fio.  153 


AUh.AnsL  t:  RaichJhold.  Miindien 


LACERATIONS  OF  GENITALIA  DURING  LABOR.    251 

coveries  in  celiotomy  without  this  complication  range 
from  26  to  100  per  cent.,  according  as  the  conditions 
are  favorable  or  unfavorable ;  that  is  to  say,  26  per 
cent,  when  labor  is  protracted  and  other  operative  at- 
tempts are  made  or  the  vesico-uterine  pouch  is  opened ; 
from  44  to  47  per  cent,  in  cases  of  protracted  labor 
with  discharge  of  the  amniotic  fluid,  but  without  at- 
tempts at  operation.  These  results  compare  rather 
favorably  with  the  results  of  Cesarean  section,  but 
they  serve  to  show  the  danger  of  any  other  obstetrical 
operations  per  vias  naturales.  The  general  practitioner 
has  no  other  recourse  than  to  extract  the  fetus  through 
the  tear  and  then  to  tampon  the  cavity,  or,  after  drawing 
the  uterus  down,  to  suture  the  lacerations  with  the  aid  of 
a  grooved  (Sims')  speculum.  This  conservative  procedure 
is  the  only  one  admissible  in  incomplete  rupture  without, 
or  with  only  partial,  escape  of  the  child  into  the  abdom- 
inal cavity,  unless  there  is  extensive  laceration  of  the 
uterine  wall  and  especially  of  the  intraligamentary  tissue, 
or  infection  has  already  taken  place.  Under  such  cir- 
cumstances vaginal  hysterectomy  or  celiotomy  with  Porro 
amputation  are  the  proper  modes  of  procedure. 

(6)  Erosions  of  the  Uterine  Wall. — As  has  been  fully 
explained  in  §§  17  and  19,  and  illustrated  in  Figs.  130- 
132,  the  fetal  skull  suffers  characteristic  indentations 
which  may  lead  to  hemorrhages,  necroses,  and  incomplete 
fractures.  The  corresponding  portion  of  the  cervix  also 
becomes  perforated  or  local  pressure-necrosis  results. 
The  seats  of  predilection  are  the  promontory,  the  spiny 
prominences  so  frequently  seen  in  the  rachitic  pelvis,  the 
symphysis,  and  the  iliopectineal  line.  The  resulting 
losses  of  substance  have  a  characteristic  circular,  funnel- 
shaped  outline.  They  usually  heal  spontaneously,  being 
at  once  incapsulated  by  the  development  of  adhesive  peri- 
tonitis.    They  do  not  give  rise  to  any  special  symptoms. 

If  the  lesion  occurs  at  the  anterior  wall  a  urinary 
fistula  is  apt  to  form.  This  occurs  in  the  great  majority 
of   cases  as  a  result  of  necrosis.     The  plug  of  necrotic 


252  PATHOLOGY  OF  LABOR. 

tissue  separates  in  a  few  days,  so  that  incontinence  is  not, 
as  a  rule,  discovered  until  the  third  or  fourth  day  of  the 
puerperium.  (For  the  treatment,  see  the  author^s  Atlas 
of  Gynecology.) 

(c)  Lacerations  of  the  Cervix. — Lacerations  at  the  os 
possess  a  certain  significance,  as  they  lead  to  characteristic 
ulcerations  (Fig.  18  in  the  text)  and  sometimes  to  acute 
parametritis. 

Deeper  tears  of  the  cervix  are  usually  produced  by 
obstetrical  instruments  and,  if  they  extend  to  the  vaginal 
vault  or  into  the  subperitoneal  connective  tissue,  may 
become  very  serious,  as  they  come  within  the  distribution 
of  the  uterine  arteries  (see  §  ],  Fig.  3).  The  diagnosis 
between  hemorrhage  due  to  atony  of  the  muscle  and  trau- 
matic hemorrhage  is  therefore  of  the  highest  importance. 
Only  when  the  uterus  feels  hard  to  the  touch  is  it  per- 
missible to  make  a  digital  examination  (always  under 
strict  aseptic  precautions)  for  the  purpose  of  examining 
the  mucous  membrane  of  the  vagina,  of  the  portio  vagi- 
nalis, and  of  the  cervix  for  the  presence  of  lacerations. 

Treatment. — The  tear  should  be  sewed  up  either  with- 
out the  use  of  a  speculum  under  the  guidance  of  two 
fingers  (in  the  dark,  after  Veit),  the  needle  being  held  in 
a  needle-holder  and  the  uterus  pressed  down  by  an  assist- 
ant, or  with  a  speculum  and  Muzeux's  tenacula. 

The  etiology  and  the  prognosis  vary  according  to  the 
site  of  the  tear.     For  practical  purposes  we  distinguish  : 

(1)  Lacerations  of  the  vaginal  vault ; 

(2)  Lacerations  in  the  central  portion  of  the  vagina ; 

(3)  Lacerations  in  the  fossa  navicularis,  with  or  with- 
out injury  to  the  perineum. 

Lacerations  of  the  vaginal  vault  are  found  almost  ex- 
clusively in  the  posterior  fornix,  and  are  due  either  to 
external  violence  or  to  direct  pressure  of  the  head  on  the 
brittle  and  inelastic  tissues  of  the  vaginal  vault,  which 
has  been  drawn  upward  by  the  violence  of  the  labor- 
pains  before  the  head  had  entered  the  superior  strait.  In 
a  normal  pelvis  the  failure  of  the  head  to  engage  in  the 


LACERATIONS  OF  GENITALIA  DURING  LABOR.    253 

superior  strait  is  due  to  some  abnormality  in  the  labor- 
pains,  /.  ('.,  partial  tetanus  or  unequal  contractions  of  the 
uterus,  to  the  improper  direction  of  the  contractions,  as 
in  pendulous  abdomen,  or  when  the  women  is  delivered 
in  a  standing  posture  with  the  body  bent  forward. 

The  tears  produced  in  this  way  are  very  extensive  and 
terminate  fatally,  either  by  undermining  the  vascular 
base  of  the  broad  ligament  and  giving  rise  to  profuse 
hemorrhage,  or,  if  the  peritoneal  cavity  is  opened,  by 
peritonitis.  More  rarely  death  results  from  the  decom- 
position of  shreds  of  tissue  in  the  cavities  on  either  side 
of  the  uterus.  The  child  and  the  fetal  membranes  are 
usually  forced  wholly  or  partially  into  the  laceration. 
The  symptoms  in  many  cases  are  not  at  all  alarming,  but 
the  prognosis  must  be  considered  unfavorable. 

Treatment. — Immediate  extraction  of  the  child  per 
vias  ncdurales  on  account  of  the  danger  of  internal  hem- 
orrhage ;  repair  of  the  laceration,  especially  of  the  serous 
membranes,  or,  if  that  is  impossible,  tamponade  and 
drainage.  If  the  operator  is  certain  that  the  peritoneum 
is  intact,  irrigation  may  be  practised  later  on,  if  the  tissues 
decompose  and  the  wound  suppurates,  or  Stschetkin's 
plan  of  making  an  extraperitoneal  lumbar  incision  with 
counter-drainage  may  be  adopted.  It  is  often  difficult  to 
determine  whether  or  not  the  peritoneum  is  intact,  as  it  is 
very  much  attenuated  and  loops  of  intestines  can  easily 
be  felt  through  it.  If  the  hemorrhage  is  uncontrollable, 
or  the  wound  is  very  badly  lacerated,  vaginal  extirpation, 
or,  if  necessary  for  the  ligation  of  vessels,  celiotomy  must 
be  resorted  to. 

Tears  in  the  central  portion  of  the  vagina  are  usually 
due  to  external  violence,  such  as  premature  elevation  of 
the  forceps,  and  are  usually  longitudinal  ;  they  rarely 
lead  to  the  formation  of  a  rectovaginal  fistula.  Much 
more  frequently  a  vesicovaginal  fistula  results,  which,  as 
a  rule,  is  not  discovered  until  several  days  later,  after  the 
separation  of  the  necrotic  tissue,  when  incontinence  of 
urine  makes  its  appearance. 


254  PATHOLOGY  OF  LABOR. 

These  tears  are  also  to  be  carefully  sewed  np.  Tears 
in  the  vagina  and  perineum  are  usually  situated  to  one 
side  of  the  posterior  column  of  the  vagina.  They  may 
occur  during  the  passage  over  the  perineum  either  of 
the  head  or  of  the  shoulder.  Occasionally  the  laceration 
is  confined  to  the  muous  membrane  of  the  fossa  navic- 
ularis,  so  that  the  perineum  and  frenulum  appear  intact 
on  tlie  outside  although  extensively  undermined  in- 
ternally. 

According  to  the  degree  of  functional  disturbance  to 
which  they  give  rise  perineal  lacerations  are  divided  into 
three  grades : 

(!)  Lacerations  of  the  frenulum; 

(2)  Lacerations  extending  to  the  sphincter  ani ; 

(8)  Lacerations  into  the  rectum. 

These  lacerations  are  to  be  at  once  repaired  in  every 
case  (for  the  technique,  see  Atlas  of  Labor  and  Operative 
Obstetrics).  If  the  sutures  are  introduced  before  the 
placenta  is  expelled,  its  subsequent  extraction  may  prevent 
primary  union.  This  mode  of  healing  can  be  expected 
to  take  place  in  general  only  wlien  the  laceration  is  re- 
paired within  the  first  six  hours;  occasionally  it  may  be 
possible  to  obtain  secondary  union,  as,  for  instance,  when 
the  laceration  has  not  been  repaired  in  the  first  place  and 
the  woman  is  obliged  to  go  back  to  work  soon  after  de- 
livery. 

Healing  may  occur  even  in  spite  of  a  marlced  rise  of  tempera- 
ture. The  author  once  saw  a  case  in  which  the  temperature 
rose  to  103. G°  F.  (39.7°  C.)  on  the  first  evening,  a  small  abscess 
having  formed,  which  ruptured  toward  the  edge  of  the  newly 
formed  frenulum  without  interrupting  the  healing  of  the  vaginal 
and  perineal  granulations. 

g3i.  DYSTOCIA  DUE  TO  ANOMALIES  IN  THE  POSITION 
AND  FORM  OF  THE  GENITAL  ORGANS,  INCLUDING 
TUMORS. 

(a)  Dystocia  due  to  Malformations  of  the  Genital  Organs. 
— In  rudimentary  organs  (uterus  unicornis)  or  in  the 
anomalies  due  to  persistence  of  the  bilateral  fetal  charac- 


DYSTOCIA.  255 

ter  of  the  organ,  such  as  uterus  bicornis,  uterus  septus, 
vagina  sej3ta,  the  sources  of  danger  during  labor  consist 
in  the  great  tendency  to  lacerations  and  in  anomalies  of 
the  labor-pains,  due  to  the  weakness  of  the  muscular 
tissue  and  their  oblique  direction  with  reference  to  the 
pelvic  inlet.  In  the  hrst  place  the  malformation  affects 
the  position  of  the  fetus.  In  uterus  septus  the  position 
is  longitudinal  with  a  preponderance  of  vertex  presenta- 
tions. In  uterus  bicornis  with  a  common  uterine  cavity 
there  is  a  greater  liability  to  pelvic  presentations ;  in 
uterus  introrsum  arcuatus  (Fig.  98)  the  lateral  expansion 
of  the  uterine  body  often  gives  rise  to  transverse  posi- 
tions of  the  fetus,  the  tendency  being  often  increased  by 
the  shortening  of  the  anteroposterior  diameter,  which 
frequently  accompanies  this  anomaly.  The  relative 
width  of  the  uterine  cavity  also  predisposes  to  placenta 
prsevia.  The  disturbances  which  take  place  during  preg- 
nancy have  been  discussed  in  §  15. 

Labor. — The  deviation  in  the  axis  of  the  gravid  horn 
of  the  uterus  from  the  very  beginning  determines  the 
expulsion  of  the  fetus  in  an  oblique  direction,  so  that  the 
opposite  wall  of  the  pelvis  (Fig.  97)  offers  an  increased 
resistance,  and  this,  when  assisted  by  the  unequal  distribu- 
tion of  the  muscular  tissue  and  frequent  displacement  of 
the  non-gravid  horn  of  the  uterus,  may  lead  to  lacera- 
tions of  the  lower  uterine  segment  or  to  an  extraordinary 
prolongation  of  labor  (missed  labor).  A  similar  effect 
may  be  produced  by  the  presence  of  a  rigid  septum  in  the 
vagina.  Severe  hemorrhage  may  result  if  the  placenta  is 
inserted  in  the  septum  of  the  uterus  which  is  capable  of 
contracting. 

A  further  obstacle  to  labor  may  be  presented  by  the 
displacement  of  the  non-gravid  horn  into  the  pouch  of 
Douglas,  which  not  rarely  occurs.  The  uterus  becomes 
wedged  in  under  the  promontory  and  obstructs  the  true 
pelvis. 

If  pregnancy  in  a  rudimentary  cornu  or  in  one  which 
is  completely  shut  off  from  the  uterine  cavity  (see  Fig. 


256  PATHOLOGY  OF  LABOR. 

Ill)  goes  on  to  term,  Cesarean  section  with  removal  of 
the  cornu  is  required. 

(b)  Dystocia  due  to  Acute  Flexion  and  Sacculation  of 
the  Uterus. — Under  this  head  are  included  anteflexion, 
lateroflexion,  and  sacculation  of  the  uterus. 

Labor. — In  anteflexion  the  force  of  the  labor-pains  or 
the  power  of  the  abdominal  muscle  may  be  defective. 
A  more  dangerous  complication  consists  in  the  head  being 
forced  against  the  promontory ;  that  is  to  say,  in  the 
sagittal  suture  being  brought  nearer  to  that  structure  (see 
Figs.  130,  131,  and  in  the  author's  Atlas  of  Labor  and 
Operative  Obstetrics,  Fig.  15,  Nagele's  obliquity);  or  in 
the  head  being  forced  down  on  the  symphysis,  thus 
causing  angulation  of  the  vertebral  column  {Atlas  of 
Labor  and  Operative  Obstetrics,  Fig.  16,  and  severer 
grades),  i.  e.,  approximation  of  the  sagittal  suture  to  the 
symphysis  (presentation  of  the  posterior  parietal  bone). 
For  further  details  see  under  Contracted  Pelves,  especially 
§§19,  20,  Nos.  2  and  3. 

Treatment. — The  anterior  displacement  of  the  fundus 
must  be  corrected  by  laying  the  woman  on  her  back  and 
maintaining  a  backward  fixation  of  the  uterus  by  means 
of  towels  and  binders.  (For  operative  procedures  see  the 
sections  just  referred  to.) 

For  similar  reasons  lateroflexion  of  the  uterus,  which 
is  a  frequent  accompaniment  of  pendulous  abdomen, 
especially  if  the  woman  lies  on  the  wrong  side  or  tosses 
about  from  side  to  side,  may  force  the  head  against  the 
lateral  wall  of  the  pelvis  and  thus  lead  to  face  or  trans- 
verse presentations.  The  treatment  consists  in  main- 
taining the  head  in  a  median  position  at  the  superior 
strait,  or  possibly  in  converting  it  into  a  footling  pres- 
entation by  means  of  pillows  placed  under  the  woman's 
body,  by  placing  her  on  the  appropriate  side,  and  by 
means  of  external  or  internal  manipulations  (version ; 
manipulations  for  correcting  the  position  of  the  fetus,  see 
Atlas  of  Labor  and  Operative  Obstetrics). 

Partial  angulation  and  sacculation  of  the  uterine  wall 


DYSTOCIA.  257 

is  observed  toward  the  end  of  pregnancy,  or  during  labor, 
whenever  any  part  of  the  uterine  wall  becomes  abnormally 
fixed.  Thus,  in  already  existing  retroflexio  uteri ;  in 
arrest  of  the  head  under  the  promontory  ;  in  perimetritic 
or  parametritic  distortions;  when  the  uterus  is  fixed  either 
too  high  or  too  far  to  one  side  and  the  anterior  wall  is 
unable  to  develop  during  pregnancy  (vagino-  and  ventro- 
fixation) ;  when  myomata  and  cysts  are  present;  when  the 
gravid  horn  of  a  uterus  bicornus  is  wedged  in  under  the 
promontory ;  and,  finally,  when  the  direction  of  the  uterine 
contraction  is  abnormal  in  pendulous  abdomen  ;  possibly, 
also,  in  retroposition  or  retroversion  of  an  anteflexed 
(generally  infantile)  uterus  in  primiparee  (Diihrssen). 

Sacculations  may  occur  in  the  anterior  or  in  the  lateral 
walls,  but  are  most  frequent  in  the  posterior  wall — partial 
retroflexion  of  the  uterus.  Labor  may  be  seriously  pro- 
tracted or  brought  to  a  standstill  if  the  head  is  forced  into 
the  sacculation.  The  external  os  fails  to  dilate  and  is 
usually  displaced  from  the  pelvic  axis,  so  that  the  head 
pushes  the  sacculated  portion  of  the  wall  farther  and 
farther  into  the  vagina ;  or  the  head  deviates  at  the  pelvic 
inlet  and  impinges  on  the  lateral  wall  of  the  pelvis,  so 
that  we  have  brow,  face,  or  transverse  presentations.  The 
danger  consists  in  laceration  of  the  uterine  segment  or 
sepsis  derived  from  old  perimetritic  foci. 

Treatment— T\\Q  first  thing  to  do  is  to  determine 
whether  the  bladder  is  full  and,  if  so,  to  empty  it  at  once 
(see  §  15,  2a).  Next,  the  presenting  portion  (head)  is  to 
be  brou2:ht  in  line  with  the  internal  os  or  with  the  pelvic 
inlet,  while  the  external  os  and  the  cervical  canal  are 
returned  to  the  pelvic  axis.  If  possible  the  primary 
obstacle  must  be  removed. 

When  there  is  partial  retroflexion  of  the  uterus  (Fig. 
103)  and  the  head  is  movable  in  the  pelvic  inlet,  podalic 
version  and  extraction  offer  the  best  prospects,  if  putting 
the  woman  in  the  proper  position  on  the  side  correspond- 
ing to  the  deviating  presenting  part  and  forcibly  pressing 
the  head  into  the  i)elvic  inlet  have  not  proved  successful. 
17 


258  PATHOLOGY  OF  LABOR, 

If  the  head  has  entered  the  true  pelvis  and  is  movable,  the 
anterior  displacement  of  the  os  should  be  corrected  with 
the  finger,  or  a  colpeurynter  should  be  introduced  into  the 
cervical  canal.  If  the  cervical  canal  fails  to  distend, 
the  vaginal  vault  should  be  opened  as  far  as  the  ex- 
ternal OS,  the  incision  extended  into  the  lower  uterine 
segment,  and  the  child  extracted  through  the  aperture 
thus  made.  In  the  case  of  cysts,  myomata,  and  uterus 
bicornis  the  force  of  the  labor-pains  is  occasionally  suffi- 
cient to  draw  the  sacculated  portion  from  the  hollow  of 
the  sacrum  up  to  the  abdominal  cavity,  even  in  cases  that 
have  obstinately  resisted  manual  reposition  ;  the  latter 
should  always  be  attempted  before  the  abdomen  is  opened 
for  the  purpose  of  performing  supravaginal  amputation 
or  total  extirpation  of  the  uterus. 

If  rupture  threatens,  the  patient  should  be  anesthetized 
and  a  Champetier-Ribes  colpeurynter  inserted,  or  the 
above-mentioned  incision  may  be  performed.  In  trans- 
verse presentations  that  have  resisted  all  attempts  at 
correction  embryotomy  or  Cesarean  section  is  indicated. 
Every  effort  should  be  made  to  preserve  the  integrity  of 
the  amniotic  sac,  as  its  preservation  materially  improves 
the  chance  of  dilating  the  cervical  canal. 

(c)  Atresise,  Stenoses,  and  other  Obstacles  to  Labor  in  the 
Soft  Parts  of  the  Parturient  Canal. — Impregnation  may 
take  place  when  there  is  the  smallest  possible  opening  in 
the  hymen,  which  may  later  even  become  entirely  closed, 
or  when  the  hymen  is  quite  intact  (hymen  septus  sive 
bifenestratus,  see  Atlas  of  Gynecology,  Fig.  2  in  the  text). 
The  head  impinges  on  this  obstacle,  which  must,  therefore, 
be  incised.  A  similar  obstacle  to  labor  is  opposed  by 
remains  of  septa  in  a  double  genital  canal  (vagina  septa, 
collura  septum,  uterus  subseptus). 

Even  after  impregnation  has  taken  place  atresise  and 
rigidity  of  the  vulva,  vagina,  and  cervix  may  be  acquired 
through  ulcerations  or  severe  inflammations  of  the  vagina; 
they  may  be  present  before  impregnation  takes  place  in 
elderly  priraiparse  after  operations  on  the  portio  vaginalis 


DYSTOCIA.  259 

(wedge-shaped  excision)  or  plastic  operations  on  the  peri- 
neum. 

A  case  of  this  kind  was  in  the  Munich  Gynecological  Clinic  in 
1892  and  1893.  Nitric  acid  had  been  injected  into  the  vagina  to 
bring  on  an  abortion.  A  few  days  before  labor  the  vagina  was 
opened  and  craniotomy  was  performed,  when  a  cicatricial  stenosis 
resulted. 

In  all  such  cases  there  is  danger  of  deep  lacerations 
extending  into  neighboring  organs,  or  of  the  external  os 
being  completely  separated  and  prolapsing  in  front  of 
the  vulva.  Hence  an  early  incision  is  required,  followed 
by  the  application  of  forceps  or  craniotomy  or,  if  the 
parturient  canal  is  obstructed  by  too  great  a  mass  of 
adhesions,  Cesarean  section  may  even  be  required.  The 
so-called  "  conglutinatio  orificii  extern!  ^'  of  primiparse 
consists  simply  in  a  stenosis  of  the  rigid  external  os,  which 
can  scarcely  be  palpated.  The  treatment  consists  in  dilating 
it  with  the  finger  and  making  shallow  incisions. 

Large  cystoceles  with  inversion  of  the  vagina  often  lead 
to  a  tumor-like  stenosis  of  the  birth-canal ;  they  are  par- 
ticularly dangerous  when  they  are  due  to  a  vesical  calculus. 
In  such  a  case  lithotomy  must  be  at  once  performed.  In 
simple  cystocele  the  bladder  should  be  immediately  evac- 
uated ;  the  concavity  of  the  catheter  must  be  directed 
downward  to  correspond  with  the  posterior  deflection  of 
the  urethra. 

A  similar  obstacle  is  presented  by  a  subcutaneous  hema- 
toma of  the  vagina  or  vulva,  which  occurs  in  one-third 
of  all  the  cases  during  labor  on  account  of  the  great 
vulnerability  of  the  venous  plexuses  and  the  increased 
intra-abdominal  pressure.  In  twin  labor  it  may  seriously 
threaten  the  life  of  the  second  twin.  As  soon  as  there  is 
danger  of  rupture  or  of  labor  coming  to  a  standstill,  the 
hematoma  should  be  incised,  the  child  rapidly  extracted, 
and  the  hemorrhage  controlled  by  ligating  the  bleeding 
vessels  or  by  tamponade. 

In  very  rare  instances  labor  may  be  obstructed  by  true 
vaginal  tumors,  fibromata,  myomata,  and  cysts,  which  act 


260  PATHOLOGY  OF  LABOR, 

much  in  the  same  way  as  the  myoma  of  the  cervix  seen 
in  Fig.  107,  which  was  spontaneously  expelled.  They 
require  the  same  treatment.     Cysts  are  to  be  punctured. 

(r/)  Labor  Obstructed  by  Uterine  Fibromata. — The  diag- 
nosis, the  effect  on  labor,  and  the  treatment  have  already 
been  discussed,  at  least  in  part,  in  §  16a.  It  remains  to 
determine  what  is  the  proper  line  of  action  when  labor  is 
already  in  progress  and  a  complication  of  this  kind  exists. 

If  the  head  is  unable  to  make  its  way  past  the  tumor 
into  the  true  pelvis  there  is  danger  of  rupture,  usually  of 
the  fundus  uteri.  Submucous  myomata  of  the  cervix 
may  be  enucleated  and  ^'  delivered  "  (Fig-  107).  Large 
intramural  myomata,  on  the  other  hand,  form  an  absolute 
hindrance  to  labor  and  are,  therefore,  the  most  dangerous. 
Tumors  situated  high  up,  within  reach  of  the  uterine  con- 
tractions, are  often  drawn  up  out  of  the  true  pelvis  with 
astonishing  ease  when  compared  with  the  difficulty  of 
manual  reposition. 

Owing  to  the  irregular  outline  of  the  pelvic  inlet — not 
to  mention  the  transverse  presentations  to  which  this  con- 
dition often  gives  rise — there  is  great  danger  of  prolapse, 
either  of  the  umbilical  cord  or  of  one  of  the  extremities. 
In  addition  there  is  great  danger  of  injury  to  tlie  cranial 
bones.  A  frequent  result  of  a  partial  obstruction  is 
placenta  prsevia,  as  is  tubal  pregnancy. 

In  addition  to  the  mechanical  obstruction  to  which  they 
give  rise  tumors  may  exert  injurious  effects  on  account 
of  changes  in  the  tissue  of  the  tumor  itself  or  of  the 
uterus.  The  fibrous  elements  undergo  rapid  ])roliferation 
and  either  become  markedly  edematous  or  undergo  myxoid 
or  colloid  degeneration  ;  the  contractile  elements  do  not 
participate  in  the  process.  In  this  way  they  increase  the 
danger  of  infection,  of  rupture,  and  of  hemorrhage,  and 
diminish  the  fn^ce  of  the  labor-pains  (missed  labor,  espe- 
cially in  intramural  myoma).  The  tumors  are  very  liable 
to  become  crushed  and  then  to  slough. 

Tlie  dangers  to  labor,  therefore,  consist  in  excessive 
duration  with  secondary  diminution  in  the  force  of  the 


DYSTOCIA.  261 

labor-pains  ;  rupture  of  the  uterus ;  obstruction  of  the 
birth-canal :  anomalies  in  position  and  especially  in  the 
attitude  of  the  child  ;  anomalies  in  the  insertion  of  the 
])lacenta  ;  and  prolapse  of  an  extremity  or  of  the  umbil- 
ical cord. 

During  the  puerperal  period  the  interference  with 
uterine  contraction  predisposes  to  hemorrhage  or  retention 
of  the  placenta. 

Treatment. — This  depends  on  the  behavior  of  the  my- 
oma. If  neither  the  force  of  the  labor-pains  nor  manip- 
ulation suffices  to  push  it  out  of  the  way  and  it  can- 
not be  extirpated,  or  if  from  its  size  and  position  it  con- 
stitutes an  absolute  hindrance  to  labor,  the  child  must  be 
delivered  by  Cesarean  section  at  term  or  when  it  has 
reached  viability.  In  most  cases  it  is  best  to  perform  a 
supravaginal  Porro  amputation  with  retroperitoneal  dis- 
posal of  the  pedicle,  or  total  extirp'ation  of  the  uterus  Avith 
the  placenta,  so  as  to  avoid  the  danger  of  sepsis  and  the 
effects  of  thrombosis  and  embolism. 

Another  source  of  danger  after  delivery  jjer  vias 
naturales  is  found  in  the  tendency  of  the  myoma  to 
slough,  so  that,  even  after  a  natural  delivery,  it  may  be 
wise  to  operate. 

On  account  of  the  elasticity  of  myomata  and  the 
changes  in  shape  produced  in  them  by  the  action  of  the 
labor-pains,  the  degree  of  pelvic  contraction  which  they 
produce  is  not  the  same  as  that  due  to  deformity  of  the 
pelvis  ;  if  the  tumor  occupies  about  one-third  of  the  pelvis 
and  cannot  be  pushed  out  of  the  way,  craniotomy  is  indi- 
cated in  vertex  presentations  and  extraction  in  pelvic 
presentations;  if  the  tumor  fills  one-half  of  the  pelvis 
Cesarean  section  is  called  for. 

(e)  Labor  Obstructed  by  Ovarian  Tumors. — The  most 
dangerous  are  the  small  solid  ovarian  tumors  which 
remain  fixed  in  the  pouch  of  Douglas  and  prevent  the 
head  from  entering  the  pelvis.  The  pressure  on  the  tumor 
leads  either  to  necrosis  or  to  rupture,  thus  forming  a 
favorable  site  for  septic  infection  ;  or  rupture  of  the  uterus 


262  PATHOLOGY  OF  LABOR. 

or  of  the  vagina  takes  place.  In  some  cases  the  tumor  is 
squeezed  flat  and  finally  pressed  up  over  the  pelvic  inlet, 
the  pedicle  in  such  cases  being  usually  torn  or  twisted. 

treatment. — If  attempts  at  reposition  are  unsuccess- 
ful, tapping  is  to  be  considered.  If  this  procedure  does 
not  suffice,  vaginal  ovariotomy  or  even  Cesarean  section, 
followed  by  removal  of  the  tumor,  may  have  to  be  per- 
formed. 

(/)  Labor  Obstructed  by  Carcinoma. — The  rigidity  of 
the  tissues  and  the  possibility  of  delivery  j9er  vias  naturales 
will  depend  on  the  amount  of  cervical  tissue  involved  in 
the  carcinomatous  infiltration.  If  it  is  found  that  the 
presenting  part  fails  to  descend,  and  the  vaginal  portion 
does  not  dilate  under  the  action  of  vigorous  labor-pains, 
it  may  be  inferred  that  the  obstacle  is  insurmountable, 
and  one  of  the  following  procedures  is  indicated  :  Deep 
crucial  incisions  in  the  portio  vaginalis  ;  incision  of  the 
lower  uterine  segment  through  the  anterior  vault  of  the 
vagina  after  the  bladder  has  been  dissected  away  ;  or, 
finally,  Cesarean  section,  followed  in  every  case  by  total 
extirpation  of  the  uterus  if  the  process  has  not  yet  ex- 
tended to  neighboring  organs,  the  body  of  the  uterus 
being  removed  through  the  abdominal  section  and  the 
cervix  through  the  vagina. 

I  22.  DYSTOCIA  DUE  TO  ANOMALIES  IN  THE  OVUM  OR 

FETUS. 

Dystocia  due  to  abnormal  position,  attitude,  and  pres- 
entation of  the  fetus  has  been  discussed  in  the  Atlas  of 
Labor  and  Operative  Obstetrics. 

(1)  Twin  and  Multiple  Pregnancies. — G.  Veit  found  in 
the  analysis  of  13,000,000  births  one  case  of  twins  to  88 
single  births,  one  case  of  triplets  to  7910  single  births, 
and  one  case  of  quadruplets  to  37,126  single  births. 
About  a  dozen  cases  of  quintuplets  have  been  reported  in 
modern  times  in  various  countries. 

Multiple  pregnancy  is  due  either  to  the  fecundation  of 
several  ova  discharged  at  the  same  menstruation  or  to  the 


DYSTOCIA.  263 

fecundation  of  a  single  ovum  containing  several  germs 
(see  Fig.  5).  In  the  latter  variety  (twins,  etc.,  from  one 
ovum)  the  fetal  membranes  are  common,  except  that  each 
fetus  has  its  special  amnion  and  the  children  are  of  the 
same  sex ;  in  the  former  variety  each  fetus  has  its  own 
chorion  or  decidua  reflexa  and  the  children  may  be  of  the 
same  or  of  different  sexes. 

In  multiple  pregnancies  from  a  single  ovum  anas- 
tomosis of  the  placental  vessels  takes  place  and  this  leads 
to  the  so-called  third  circulation.  If  the  latter  is  not 
symmetrical  there  results,  according  to  Schatz,  a  diifer- 
ence  in  the  development  of  the  various  fetuses.  If  one 
portion  of  the  placental  system  is  insufficient  the  cor- 
responding fetus  dies  and  is  known  as  fetus  papyraceus, 
because  it  becomes  miuumified  and  pressed  flat  by  its 
fellow  (Fig.  100). 

The  diagnosis  of  twin  pregnancy  is  determined  by 

(1)  The  palpation  of  more  parts  of  ■  the  same  kind  than 
can  be  accounted  for  by  one  child  (two  amniotic  sacs,  two 
heads,  and  more  than  four  extremities) ; 

(2)  By  the  palpation  of  parts  in  such  a  situation  that 
they  cannot  possibly  belong  to  the  same  child  ; 

(3)  By  hearing  fetal  heart-sounds  distinctly  in  two 
widely  separated  areas  and  possibly  with  varying 
rhythms ; 

(4)  By  the  possibility  of  varying  the  position  of  one 
child  by  means  of  pressure  on  the  presenting  part  with- 
out aifecting  that  of  the  other. 

Occasionally  a  longitudinal  groove  can  be  made  out  on 
the  abdomen. 

Labor. — As  a  rule,  both  twins  are  delivered  in  ver- 
tex presentations,  but  pelvic  or  abnormal  presentations 
are  much  more  frequent  in  multiple  than  in  single 
births  ;  in  more  than  two-thirds  of  all  the  cases  labor 
takes  place  prematurely.  It  is  protracted  for  the  first 
child  and  accelerated  for  the  remaining  ones.  The 
mortality  is  greater  in  multiple  than  in  single  births, 
especially  for  boys,  because,  according  to  Veit,  they  are 


264  PATHOLOGY  OF  LABOR. 

larger  and  possess  less  vitality.  The  placenta  is  usually 
delivered  after  the  last  child  is  born  ;  often  the  uterus 
fails  to  contract,  in  which  case  postpartam  hemorrhages 
must  be  guarded  against  by  the  administration  of  ergot. 
The  interval  between  the  delivery  of  the  two  children 
may  amount  to  several  hours.  If  the  placenta  of  the 
second  child  appears  before  the  latter  is  born  it  must,  of 
course,  be  extracted  with  all  possible  vspeed. 

The  placental  extremity  of  the  umbilical  cord  of  the 
jfirst  child  must  always  be  ligated  in  order  to  prevent  the 
second  child  from  bleeding  to  death. 

(2)  Malformations. — These  rarely  form  an  obstacle  to 
labor.  The  most  frequent  form  is  internal  hydrocephalus, 
consisting  in  dropsy  of  the  lateral  ventricles.  In  milder 
grades  there  is  very  little  alteration  in  ±he  fontanels  and 
sutures,  and  it  is,  therefore,  difficult  to  make  the  diag- 
nosis during  labor.  In  severer  grades  with  an  effusion 
up  to  1  pint  (500  gm.)  the  cerebral  substance  becomes 
much  attenuated,  the  convolutions  are  completely  flat- 
tened, and  the  entire  skull  converted  into  a  flaccid  bag  of 
skin,  as  the  result  of  the  excessive  gaping  of  the  sutures 
and  fontanels. 

The  condition  is  often  associated  with  spina  bifida  and  with 
malformations  of  the  spine  and  spinal  cord,  of  the  diaphragm,  of 
the  abdominal  parietes  (umbilical  hernia),  with  total  absence 
of  one  kidney,  talipes  varus,  congenital  rachitis  (micromelia), 
and  with  other  forms  of  dropsy,  such  as  ascites  and  polyhy- 
dramnion.  Several  hydrocephalous  infants  may  be  born  by  the 
same  mother. 

The  deformity  often  gives  rise  to  a  pelvic  presentation 
because  there  is  less  room  for  the  head  in  the  lower 
uterine  segment  than  in  the  fundus,  into  which  it  is  forced 
by  the  uterine  contractions. 

The  diagnosis  is  difficult  to  make  during  labor.  It 
is  based  on  the  wide  separation  of  the  fontanels  and 
sutures,  on  the  small  triangular  shape  of  the  face  in  com- 
parison with  the  large  globular  skull,  and  on  the  diffi- 
culties encountered  by  the  presenting  or  aftercoming  head 


DYSTOCIA.  265 

in  passing  throngh  the  normal  pelvic  inlet ;  these  signs 
can  be  detected  only  with  the  entire  hand  in  the  uterus. 

The  most  difficult  stage  of  labor  is  the  entrance  of  the 
head  into  the  pelvic  inlet  (Fig.  157).  Under  the  action 
of  the  labor-pains  the  skull  balloons  out  like  a  bladder 
and,  being  in  the  horizontal  position,  presents  the  largest 
periphery  and  the  largest  diameter.  The  deeper  the  an- 
terior parietal  bone  is  forced  into  the  pelvic  canal  the 
more  favorable  is  the  prospect  that  at  least  one  segment 
will  effect  an  entrance  into  the  superior  strait ;  for  in- 
stance, one-half  the  skull,  or  a  brow,  or  anterior  fontanel 
presentation.  Tiiis  tends  to  distribute  the  tension  so  that 
it  acts  partially  above  and  partially  below  the  superior 
strait.  In  this  way  labor  may  be  terminated  sponta- 
neously in  one-fourth  of  all  cases,  although  the  prominent 
bony  portions  of  the  advancing  segment  are  very  apt  to 
produce  lacerations  in  the  swollen  portio  vaginalis.  In 
some  cases  perforation  of  the  skull  is  called  for  on  ac- 
count of  the  danger  of  rupture  following  the  excessive  dis- 
tention of  the  lower  uterine  segment. 

The  size  of  the  head  may  be  abnormal  as  the  -result  of 
fissures  in  the  skull  and  hernial  protrusions  (meningocele 
frontalis,  superior,  posterior,  epignathus).  Their  inter- 
ference with  labor  is,  however,  less  than  in  the  case  of 
marked  hydrocephalus,  because  the  hernial  sacs  are  com- 
pressible and  the  skulls  are  usually  small.  A  more 
serious  obstacle  is  found  in  normal  skulls  of  unusual  size 
and  hardness  with  correspondingly  broad  shoulders, 
especially  in  the  children  of  elderly  primipar?e.  Forceps, 
version,  and  extraction  of  the  aftercoming  head,  crani- 
otomy, decapitation,  and  cleidotomy  should  be  tried  in 
succession.  Hemicephalic  and  anencephalic  monsters  de- 
scend in  the  so-called  ''  face  presentation  '^  (Fig.  154). 

The  trunk  may  be  enlarged  from  the  presence  of  hernial  sacs, 
spina  bifida,  and  omphaloceles  (hernia  of  the  umbilical  cord, 
ectopia  viscerum).  tumors  (coccygeal  teratomata),  and  dropsical 
swellings  of  the  body  (ascites,  distended  bladder,  and  hydrone- 
phrosis due  to  atresia  of  the  urethra.  Fig.  158).     The  diagnosis 


266  PATHOLOGY  OF  LABOR. 

Fig.  154.  Presentation  of  an  Anencephalus  in  so-called  Face  Pres- 
entation. 

Fig.  155.  Presentation  of  Dicephalus  DibracMus. 

Fig.. 156.  Presentation  of  Thoracopagus  (copied  from  Kiistner). 

Fig.  157.  Hydrocephalus  Presenting  with  Head  in  Partial  Flexion ; 
excessive  distention  of  the  lower  uterine  segment  with  high  position  of 
the  contraction-ring,  C.  R.  (modified  from  Band!). 

Fig.  158.  Distention  of  Bladder  and  Ureters  with  secondarj^  hydro- 
nephrosis, due  to  atresia  of  the  urethra  combined  with  ascites ;  a  coil  of 
the  umbilical  cord  has  prolapsed  (modified  from  v.  Hecker). 


cannot  be  made  with  certainty.     The  condition  may  call  for  ver- 
sion, craniotomy,  or  incision  with  the  longSiebold  scissors. 

Among  other  complications  may  be  mentioned  double  monsters. 
Figs,  155  and  156  illustrate  the  presentation  of  a  diceplialus  di- 
brachius  and  of  a  thoracopagus.  The  diagnosis  can  be  made  only 
after  labor  has  begun  by  actual  palpation  of  the  monstrosity. 
Besides  being  very  rare,  these  deformities  are  attended  with  little 
dangers  to  labor,  as  they  practically  always  lead  to  abortion  or 
premature  labor. 

(3)  Dystocia  due  to  Anomalies  in  the  Umbilical  Cord  and 
Fetal  Membranes. — The  life  of  the  fetus  may  be  endan- 
gered by  compression  of  the  umbilical  cord  when  it  forms 
loops  and  coils,  which  may  even  be  converted  into  true 
knots  by  the  fetus  slipping  through  them  (this  may  occur 
as  late  as  the  fourth  month),  by  prolapse  of  the  cord 
(Fig.  1 58),  or  bv  torsion  of  the  cord  during  pregnancy 
(Figs.  88  and. 100). 

The  causes  of  prolapse  of  the  umbilical  cord  are  the 
same  as  those  which  produce  prolapse  of  the  extremities, 
namely,  failure  on  the  part  of  the  large  presenting  part 
to  fill  the  true  pelvis.  Compression  can  usually  be  de- 
tected by  hearing  the  funic  souffle  (see  §§  6  and  7).  A 
cord  may  be  felt  pulsating  synchronously  with  the  fetal 
heart.  An  attempt  at  reposition  should  immediately  be 
made  (after  the  method  indicated  in  Fig.  ^b,  Atlas  of 
Gynecology),  or,  better,  version  should  be  performed  and, 
if  the  OS  is  completely  dilated,  immediately  followed  by 
extrnction  ;  if  the  os  is  not  sufficiently  dilated,  combined 
version  after  Fehling  should  be  employed,  one  extremity 
being  left  in  the  vagina  with  a  fillet  attached. 


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DYSTOCIA.  267 

As  a  rule,  looping  of  the  umbilical  corJ  leads  to  no 
disturbance  until  toward  the  end  of  labor,  when  the  rela- 
tive shortening  of  the  cord  may  form  a  more  or  less 
serious  obstacle.  Tlie  diagnosis  is  difficult;  the  condi- 
tion may  be  suspected  if  the  rotation  of  the  head  on  the 
floor  of  the  perineum  is  unduly  delayed,  the  labor-pains 
increase  in  force,  the  fundus  of  the  uterus  becomes  pain- 
ful, the  recurrence  of  the  fetal  heart-tones  in  the  intervals 
between  labors  is  delayed,  if  the  child  ap})ears  restless  or, 
possibly,  if  the  funic  souffle  is  heard.  Sometimes  it  is 
possible  to  feel  a  coil  around  the  neck  of  the  fetus 
throutrh  the  rectum. 

There  is  danger  of  the  child  becoming  asphyxiated  on 
account  of  hemorrhage,  not  only  in  placenta  previa  but 
also  in  velamentous  insertion  of  the  placenta.  Fig.  14 
in  the  text  shows  at  once  how  easily  a  vessel  may  be  torn 
under  these  circumstances,  hence  the  child  should  be  de- 
livered with  all  possible  speed,  the  amniotic  sac  being 
preserved  intact  as  long  as  possible.  The  diagnosis  is 
made  by  feeling  the  pulsating  vessels  in  the  external  os. 
In  puncturing  the  sac  care  should  be  taken  to  choose  a 
non-vascular  area. 

Retention  of  the  placenta  is  sometimes  due  to  adhesion 
of  the  placenta  following  endometritis,  but  more  fre- 
quently to  excessive  size  of  the  placenta  or  angulation  of 
the  uterine  wall.  In  the  former  case  the  placenta  must 
be  detached  with  the  hand  under  strict  antiseptic  precau- 
tions (see  Atlas  of  Labor  and  Operative  Obstetrics,  Fig. 
42) ;  but,  as  a  rule,  it  is  better  to  allow  the  mother  to 
rest  if  there  is  no  hemorrhage  and  to  give  ergot  or  mor- 
phine to  quiet  agitation. 

Premature  separation  of  a  normally  implanted  placenta 
occurs  as  a  result  of  delayed  rupture  of  the  amniotic  sac, 
traumatism,  nephritis,  eclampsia,  infectious  diseases,  and 
of  all  the  conditions  which  produce  abortion. 

Symptoms. — Hemorrhage  :  internal  when  the  blood  ac- 
cumulates behind  the  placenta,  external  w^ien  it  makes 


268  PATHOLOGY  OF  LABOR. 

its  way  into   the  cervix  past  the  loosened  edge  of  the 
ovum.     The  condition  is  extremely  dangerous. 

Treatment. — If  the  cervical  canal  is  at  least  partially 
dilated  immediate  delivery  should  be  effected  either  by 
forced  labor  {accouchement  force),  colpeurynter,  or  by 
Cesarean  section  ;  if  the  uterus  is  atonic  and  the  hemor- 
rhage cannot  be  controlled  by  hot  injections,  tamponade 
or  the  exhibition  of  ergot  may  be  resorted  to. 

§  23.  ANOMALIES  IN  THE  LABOR=PAINS.— INTERDE= 
PENDENCE  BETWEEN  LABOR  AND  DISEASES  OF 
OTHER  THAN  THE  SEXUAL  ORGANS. 

For  the  purely  functional  anomalies  of  labor-pains  it 
is  often  impossible  to  demonstrate  any  local  anatomical 
cause,  and  they  must,  therefore,  be  classified  among  the 
disturbances  of  innervation  and  metabolism,  except  in 
those  cases  in  which  a  distinct  constitutional  or  other 
organic  disease  can  be  demonstrated. 

GENERAL  REMARKS  ON  DIAGNOSIS  AND  INDICATIONS 
FOR  OPERATION  IN  DYSTOCIA. 

So  far  the  discussion  has  been  limited  to  the  purely 
anatomical  disturbances  of  pregnancy  and  labor,  which, 
for  diagnostic  purposes,  may  be  grouped  schematically, 
according  to  causes,  as  follows  : 

I.  Abnormal  resistance  on  the 'part  of  the  mother. 

(1)  Contracted  pelves. 

(2)  Stenosis,  malformations,  arrest  of  development  or  tumors 
of  the  soft  parts. 

IL  Abnormal  resistance  on  the  part  of  the  fetus. 

(1)  Unfavorable  presentation,  position,  and  attitude  of  the  fetus. 

(2)  Malformations  of  the  fetus  (hydrocephalus,  tumors,  tera- 
tomata). 

(3)  Anomalies  in  the  shape,  contents,  and  position  of  the  fetal 
membanes,  and  of  the  umbilical  cord. 

III.  Abnormally  diminished  resistance  on  the  part  of  the  bony 
and  of  the  soft  tissues  of  the  birth-canal  on  the  one  hand,  and  of 
the  child  on  the  other  hand,  when  the  expulsive  forces  are  normal 
or  increased — producing  transverse  position  of  the  head  or  precipi- 
tate delivery. 


AyOMALIES  IS  THE  LABOR-PAINS.  269 

We  now  have  to  discuss  another  group,  which  includes 
simple  functional  disturbances  of  labor  due  either  to 
anomalies  in  the  abdominal  ])re5sure  and  in  the  force  of 
the  labor-pains,  or  to  constitutional  diseases  or  other 
defects  of  the  entire  organism.     Accordingly,  ^ve  have  : 

IV.  Functional  disturbances  of  labor  by 

(1)  Anomalies  of  the  labor-pains. 

(2)  Other  diseases  of  the  mother. 

Operative  interference  is  indicated  only  when  the 
sequels  of  these  anomalies  distinctly  threaten  the  life  of 
either  mother  or  child.  These  sequels  and  symptoms 
indicating  operative  interference  we  have  found  to  be  the 
following  : 

A.  On  the  part  of  the  mother : 

I.  Symptoms  in  the  genital  tract. 

(1)  Excessive  distention  of  the  lower  uterine  segment ;  upward 
displacement  of  the  contraction-ring  from  a  hand's  breadth  above 
the  symphysis  to  the  level  of  the  umbilicus  or  higher;  presence 
of  pain  during  the  intervals  between  the  uterine  contractions; 
small  and  weak  pulse. 

(2)  Rupture  of  the  uterus  (see  §  20(7)  with  complete  escape  of 
the  child  into  the  abdominal  cavity  :  symptoms  of  shock,  recession 
of  the  presenting  part,  and  hemorrhages  from  the  genitalia. 

(3)  Impending  rupture  of  an  ectopic  gestation-sac  (§§  156,  17) 
or  of  a  cyst  (§  16t/,  or  of  a  hematoma  or  thrombus  in  the  vulva, 
I  21c,  especially  during  the  birth  of  a  twin),  or  of  an  excessively 
dilated  bladder,  as  in  the  case  of  an  incarcerated  retroflexed  uterus 
(^216). 

(4)  Impending  perforation  from  erosion,  localized  pressure- 
necroses  (I  206  I,  lacerations  of  the  vagina  and  perineum  (|  2Qd  in 
conditions  of  rigidity,  stenosis,  and  funnel-shaped  pelves,  indicated 
by  pallor  of  the  frenulum). 

(5)  Marked  pain  in  the  pelvic  joints,  a  sign  of  impending  lacer- 
ation of  the  joint  capsules  (contracted  pelves,  |  18). 

(6)  Acute  inversion  of  the  uterus  f§  23,  Xo.  1). 

(7)  Hemorrhages  in  placenta  praevia,  premature  separation  of 
the  placenta,  retained  placenta,  atony  of  the  uterus  after  labor, 
and  with  the  above-mentioned  injuries. 

II.  General  symptoms. 

(1)  Infectious  intoxications  with  fever  or  comatose  or  hectic 
conditions:  (a)  Sepsis  with  a  temperature  of  100.4°  F.  (38°  C), 
pulse  100  and  over,  from  local  injuries  of  the  genital  tract  or  the 
decomposition  of  a  fetus.     (6)  Eclampsia  (see  1 13).     (c)  Tuber- 


270  PATHOLOGY  OF  LABOR 

ciilosis  {I  14)  ;  the  prognosis  in  labor  is  often  serious  on  account 
of  the  loss  of  blood  and  the  muscular  strain,  hence  artificial 
termination  of  labor  and  anesthesia  are  indicated  in  the  second 
stage.  On  the  other  hand,  pregnancy  itself  usually  runs  a  favor- 
able course. 

(2)  Other  organic  diseases  unfavorably  influenced  by  labor,  for 
instance,  cardiac  lesions  (^  14),  which,  according  to  Fritsch,  are 
apt  to  bring  on  cardiac  paralysis  and  pulmonary  edema  on 
account  of  the  increase  in  the  blood-pressure  due  to  the  labor- 
pains.     Extreme  debility  and  anemia. 

B.  Symptoms  on  the  part  of  the  fetus. 

(1)  Persistent  retardation  of  the  fetal  heart-sounds  down  to 
100  or  less,  or  persistent  acceleration  to  160  or  over,  with  decrease 
in  the  force  of  the  impulse.     Funic  souffle. 

(2)  Passage  of  meconium. 

(3)  Prolapse  of  the  umbilical  cord  [I  22). 

(4)  Hemorrhages  from  fetal  placental  vessels  in  velamentous 
insertions  or  in  placenta  prsevia  (^  22). 

I.  Anomalies  in  the  Labor=pains. 

{A)  Increase  in  the  Force  of  the  Labor-pains. — Tetanus 
uteri  (Wehensturm)  occurs  when  the  resistance  is  insuper- 
able, as  in  transverse  presentations  after  discharge  of  the 
amniotic  fluid,  and  particularly  after  protracted,  ill-advised 
attempts  at  delivery,  or  after  the  exhibition  of  ergot  during 
labor.  These  tonic  contractions,  while  they  in  no  way 
assist  the  act  of  parturition,  are  very  apt  to  produce  rup- 
ture of  the  lower  uterine  segment  and  death  of  the  fetus. 

Treatment. — The  labor  is  to  be  at  once  terminated  in 
transverse  presentations  by  means  of  embryotomy,  the 
spasm  of  the  uterus  being  first  allayed  by  complete  anes- 
thesia or  by  the  injection  of  \  gr.  (0  015  gm.)  of  morphine 
with  y^Q^  gr.  (0.0005  gm.)  of  atropine.  Very  often,  how- 
ever, it  is  impossible  to  relax  the  uterus  by  giving  an 
anesthetic  if  the  contractions  have  already  led  to  excessive 
dilatation  of  the  lower  uterine  segment,  besides,  the  dan- 
ger of  infection  is  increased  by  the  administration  of  a 
narcotic  when  the  temperature  is  elevated  and  the  woman 
is  much  debilitated  ;  in  such  cases,  therefore,  embryotomy 
is  the  proper  procedure. 

Spastic  strictures  result  from  the  same  causes  that  pro- 


ANOMALIES  IN  THE  LABOR-PAINS.  271 

duce  tonic  spasmodic  contractions,  and,  of  course,  occur 
only  in  situations  supplied  with  sphincter-like  muscles,  as 
at  the  uterine  orifices  of  the  tubes  and  at  the  external  os 
(see  Figs.  64  and  65).  They  occur  rarely  during  lai:)or, 
as,  for  instance,  in  Kaltenbach's  case,  which  is  of  medico- 
legal interest  in  that  the  stricture  was  situated  in  the 
region  of  the  internal  os  and  caused  a  constriction  on  the 
neck  similar  to  that  produced  by  a  coil  of  the  umbilical 
cord.  Usually  they  occur  during  the  postpartum'  period, 
and  may  in  some  cases  produce  retention  of  the  placenta. 

Treatment. — The  condition  calls  for  the  administration 
of  an  anesthetic. 

Analogous  to  this  last  variety  of  spasmodic  contractions 
we  have  the  partial  convulsive  labor-pains  which  occur 
not  infrequently  and  affect  various  asymmetrical  portions 
of  the  uterine  muscle.  Their  effect  is  to  exert  unequal 
pressure  on  the  fetus  or  ovum,  so  that  labor  fails  to  pro- 
gress in  spite  of  the  apparent  force  of  the  contractions. 
The  spasm  is  especially  apt  to  occur  in  nervous  and  chlo- 
rotic  women. 

Treatment. — The  treatment  is  the  same  as  for  atony 
of  the  uterus,  to  which  the  condition  is  closely  allied  ;  i.  e., 
narcotics  or  possibly  a  single  profound  anesthetization. 

Abnormally  vigorous  labor-pains  with  lessened  resist- 
ance in  the  birth-canal  and  fetus  lead  to  ])recipitate 
delivery.  The  excessive  force  of  the  labor-pains  is  due 
to  the  presence  of  a  hypertrophic  substratum  in  the  mus- 
cularis  of  the  fundus,  a  condition  which  is  not  rarely 
hereditary.  According  to  v.  Winckel,  an  additional  pre- 
disposing cause  is  found  in  multiple  births  and  abnormal 
shortening  of  the  umbilical  cord. 

Treatment. — The  woman  is  placed  on  her  side  and 
forbidden  to  bear  down.  The  perineum  should  be  pro- 
tected from  the  very  beginning.  If  the  condition  changes 
to  partial  convulsive  labor-pains  anesthesia  should  be 
induced  or  a  mustard-plaster  applied. 

{B)  Diminution  in  the  Force  of  the  Labor-pains.— This 
may  be : 


272  PATHOLOGY  OF  LABOR. 

(a)  Primarily  either  as  the  result  of  a  general  weakness 
due  to  anemia,  starvation,  or  disease  in  a  debilitated 
woman ;  or  as  a  result  of  defective  development  of  the 
uterine  muscle,  be  it  physiological,  on  account  of  age 
(very  young  or  very  old  primiparae),  or  dependent  upon 
defective  involution,  especially  after  premature  labors,  or 
upon  malformations  of  the  uterus  (uterus  bicornis,  unicor- 
nis, see  §§  15  and  21),  or  upon  tumors  in  the  uterine  wall. 

(6)  Secondary,  resulting  from  abnormal  distention  (poly- 
hydramnion,  multiple  pregnancy,  etc.),  loss  of  blood 
(placenta  prsevia),  inflammatory  disease  (injuries  and  peri- 
metritic adhesions  of  the  uterus,  hysteropexy),  or,  finally, 
from  displacement  of  the  uterus.  Among  indirect  causes 
may  be  mentioned  insufficient  abdominal  pressure  during 
the  second  stage  of  labor  and  congestion  and  inflammation 
of  the  pelvic  organs. 

Diagnosis. — AH  these  etiological  factors  must  be  care- 
fully taken  into  consideration,  and  the  force  and  dura- 
tion of  the  pains  and  of  the  intervals  accurately  noted 
by  the  condition  of  the  fundus,  the  progress  of  the 
presenting  part,  and  the  dilatation  of  the  entire  cervical 
canal.  The  bladder  and  rectum  must  be  carefully  ex- 
amined and  emptied  if  necessary.  Finally,  the  general 
condition  of  the  patient  as  to  temperature  and  pulse  must 
be  determined,  and  after  the  discharge  of  the  amniotic 
fluid  the  fetal  heart-sounds  should  be  counted. 

Atony  of  the  uterine  muscle  leads  to  dangerous  post- 
partum hemorrhages. 

Treatment. — This  consists  in  stimulating  the  labor- 
pains  bv  means  of  hot  baths,  bv  hot  vaginal  douches  at 
from  93°  to  100°  F.  (34°  to  38°  C— a  pailful  of  steril- 
ized 0.6  per  cent,  salt  solution  or  0.25  per  cent,  lysol 
solution  being  injected  every  one  or  two  hours),  or  by  hot 
poultices,  reaching  from  the  fundus  to  the  symphysis ;  in 
the  administration  of  diaphoretics  and  stimulants,  the 
patient  being  first  thoroughly  quieted  and  allowed  to  sleep, 
and  the  bladder  and  rectum  emptied.  If  all  these  measures 
fail,  and  if  the  os  fails  to  dilate  and  the  head  is  already 


ANOMALIES  IN  THE  LABOR-PAINS.  273 

deeply  engaged,  a  colpeiirynter  should  be  introduced. 
This  is  indicated  especially  in  overdistention  of  the  uterus 
due  to  multiple  pregnancy  or  polyhydramnion,  in  which 
case  the  amniotic  sac  should  also  be  punctured  early;  it  is 
not  so  appropriate,  liowever,  in  painful  affections. 

If  labor  does  not  terminate  spontaneously,  all  the  vari- 
ous operations  for  extraction  may  be  considered :  Manual 
expression  of  the  fetus,  after  Kristeller,  Fehling's  and 
Ritgen's  manipulations  to  hasten  the  delivery  of  the  head 
(see  Atlas  of  Labor  and  Operative  Obstetrics),  the  applica- 
tion of  forceps  if  the  child's  life  is  in  danger  or  the 
mother  becomes  completely  exhausted,  and  in  the  third 
stage  of  labor  expression  of  the  placenta  after  the  uterus 
has  become  firmly  contracted,  either  spontaneously  or  after 
half  an  hour's  rubbino;  and  kneadino^  of  the  fundus  and 
of  the  posterior  wall,  or,  if  the  placenta  is  not  delivered 
and  hemorrhage  occurs  instead,  extraction  of  the  placenta. 
Ergot,  ergotin,  or  cornutin  may  he  given  even  in  the 
expulsive  stage  if  there  is  no  abnormal  resistance,  pro- 
viding immediate  artificial  termination  of  labor  is  not 
intended. 

Such  abnormal  resistance  is  often  due  to  secondary 
diminution  in  the  force  of  the  labor-pains,  which  will 
now  be  considered. 

(C)  Seoondary  Diminution  in  the  Force  of  Lahor-pains, 
— If  labor  is  too  long  delayed,  the  child  dies  after  the 
discharge  of  the  amniotic  fluid  and  there  is  constant 
danger  of  infection  from  the  invasion  of  micro-organisms, 
hence  artificial  delivery  is  indicated,  massage  of  the  fundus 
being  kept  up.  Ergot  is  to  be  administered  at  the  moment 
of  delivery. 

If  the  atonic  bleeding  continues  in  spite  of  these 
measures — as  may  occur  in  hemophilia,  arteriosclerosis, 
cardiac  lesions,  chronic  nephritis,  insufficient  development 
of  the  muscle  at  the  placental  site — a  hand  should  be 
introduced  into  the  vaginal  vault,  the  uterus  bent  over 
forward  and  kneaded  between  the  two  hands.  In  desper- 
ate cases  the  portio  vaginalis  should  be  drawn  down  to  the 

18 


274  PATHOLOGY  OF  LABOR. 

vulva  with  Miizeux's  tenacula  and  covered  with  sterile 
gauze.  Tliis  procedure,  by  distorting  and  obstructing  the 
uterine  vessels,  will  stop  the  blood-supply  and  thus  arrest 
the  hemorrhage,  while  the  increased  amount  of  carbon 
dioxide  in  the  blood  brings  on  contraction  of  the  uterine 
muscle. 

A  very  serious  but  fortunately  rare  consequence  of  in- 
sufficient contraction  of  the  lower  portion  of  the  uterus  is 

Inversion  of  the  Uterus. — It  occurs  chiefly  as  a  result 
of  improper  treatment  during  the  third  stage  of  labor, 
such  as  undue  traction  on  the  umbilical  cord  before  the 
placenta  is  separated  and  manual  pressure  on  the  uncon- 
tracted  uterus.  It  may  be  partial,  invaginating  the  fundus 
in  the  shape  of  a  funnel,  or  complete,  in  which  case  the 
spherical  body  of  the  uterus  is  forced  through  the  internal 
OS  ;  the  condition  calls  for  immediate^  re-inversion  or  the 
introduction  of  a  colpeurynter  after  the  placenta  has  sepa- 
rated (see  Atlas  of  Gynecology). 

2.   Interdependence  Between  Labor  and   Diseases  of  Other 

Organs. 

The  most  important  disturbances  and  dangerous  com- 
plications occur  in  the  presence  of  cardiac  insufficiency 
and  tuberculosis.  In  cardiac  insufficiency  without  com- 
pensation and  with  degeneration  of  the  heart-muscle  (see 
§  14)  death  may  occur  suddenly  during  labor  as  a  result 
of  pulmonary  edema  and  profuse  dropsical  effusions.  In 
other  cases  the  heart  is  arrested  by  cerebral  or  cardiac 
anemia  secondary  to  venous  stasis  in  the  intestinal  blood- 
vessels. During  the  third  stage  there  is  great  danger  of 
hemorrhage  on  account  of  the  atony  of  the  uterus.  In 
the  subsequent  course  of  the  puerperium  there  is  an  in- 
creased liability  to  infection  on  the  part  of  the  tissues  on 
account  of  the  disturbances  to  circulation  and  nutrition. 
A  moderate  postpartum  hemorrhage  relieves  the  patient  and 
is  not  necessarily  dangerous.  If  dyspnea  occurs  during 
labor  (see  the  scheme  in  this  section  under  Anomalies  of 
Labor-pains)  the  woman  is  placed  in  a  sitting  posture  and 


ANOMALIES  TX  THE  LABOR-PAINS.  275 

hypodermai:ic  injections  of  camphor  and  ether  are  ad- 
ministered, or,  if  necessary,  the  amniotic  sac  is  prema- 
turely punctured. 

If  dangerous  symptoms  develop,  the  child  should  be 
extracted  as  early  as  possible,  but  not  too  rapidly. 
Anesthetization  may  be  useful  in  some  cases.  Dilatation 
of  the  OS  is  effected  by  means  of  the  colpeurynter.  Un- 
less the  postpartum  hemorrhage  produces  alarming  symp- 
toms ergotin  is  contra-indicated  ;  on  the  other  hand,  the 
application  of  a  sand-bag  to  the  abdomen  is  very  useful. 
During  the  first  four  days  of  the  puerperium  ether  may 
be  given,  after  that  digitalis  or  strophanthus. 

The  prognosis  of  labor  and  the  puerperium  in  lung 
diseases  (see  §  14),  be  they  acute,  as  croupous  pneumonia 
or  even  influenza,  or  chronic,  as  tuberculosis,  is  very  un- 
favorable. The  consequences  to  be  feared  are  postpartum 
hemorrhages  on  the  one  hand,  rapid  loss  of  strength  and 
exacerbation  of  the  systemic  disease,  and  pulmonary 
edema  on  the  other  hand. 

Influenza  is  often  followed  by  septic  infection  (metritis, 
peritonitis)  and  the  discharge  of  fetid  lochia,  even  in 
cases  in  which  there  has  been  no  vaginal  exploration  nor 
even  support  of  the  perineum  during  labor.  Similar 
danger  exists  in  the  case  of  erysipelas,  and  the  prognosis 
of  labor  is  even  more  unfavorable. 

The  sequels  of  chronic  nephritis  in  the  case  of  the 
parturient,  and  much  more  rarely  of  the  puerperal,  woman 
in  the  form  of  eclam])sia  and  its  treatment  have  been 
discussed  in  §  13,  in  connection  Avith  Premature  Labor. 

The  influence  of  disturbances  of  innervation  upon  labor  mani- 
fests itself  in  various  ways,  and  is  much  more  extensive  and  of 
more  frequent  occurrence  than  might  be  supposed  from  the 
cursory  manner  in  which  the  subject  is  usually  treated  in  text- 
books in  the  chapter  on  Anomalies  of  Labor-pains.  Disturb- 
ances in  the  form  of  simple  neuroses  are  of  serious  import  for 
two  reasons:  either  they  may,  like  hyperemesis  gravidarum,  be 
followed  by  serious  consequences  to  the  child  and  occasionally 
to  the  mother;  or,  on  the  other  hand,  they  may,  by  simulating 
alarming  symptoms,  induce  the  beginner  to  resort  prematurely  to 


276  PATHOLOGY  OF  LABOR. 

active  interference  and  thereby  expose  the  woman  to  the  dangers 
of  injury.  Again  and  again  men  of  the  widest  experience,  like 
V.  Winckel,  who  learned  their  profession  during  a  period  when 
any  form  of  unnecessary  interference  was  discountenanced,  have 
insisted  that  every  beginning  practitioner  should  seize  every  op- 
portunity to  observe  physiological  labors  as  accurately  as  pos- 
sible, and  this  dictum  still  retains  all  its  force  even  in  these  days 
of  antisepsis,  anesthesia,  and  improved  technique.  Accurate 
recognition  of  any  deviation  from  the  physiological  process  dur- 
ing labor  is  the  only  protection  against  harmful  interference, 
especially  now  that  we  have  acquired  a  knowledge  of  the  nervous 
pheni)mena. 

Among  the  causes  of  functional  anomalies  in  the  innervation 
the  author  has,  above  all,  observed  alterations  in  the  type  of  the 
labor-pains.  In  addition  to  the  subjective  symptoms  of  increased 
pain,  localized  especially  near  the  sacrococcygeal  extremity  or  in 
one  horn  of  the  uterus,  the  effects  of  such  nervous  disturbances 
manifest  themselves  objectively  in  the  diminution  of  the  force  of 
the  contractions.  In  neuropathic  individuals  not  suffering  from 
any  special  gynecological  disease  very  painful  gestation  pains 
often  make  their  appearance  during  the  last  six  to  ten  weeks, 
occurring  usually  at  night,  associated  with  profuse  sweating. 
During  parturition,  which  may  be  premature  or  abnormally 
delayed,  the  severity  of  the  pains  becomes  abnormally  in- 
creased, and  the  contractions,  which  are  manifestly  asymmetrical 
and  may  even  partake  of  the  partial  tetanic  type,  fail  to  bring 
about  sufficient  dilatation  of  the  external  os,  which  is  often  de- 
layed for  hours  or  even  for  days  without  any  apparent  reason. 
Premature  rupture  of  the  atnniotic  sac  without  endometritic 
symptoms  is  a  very  common  occurrence.  If  the  abdominal  walls 
are  relaxed,  the  head  may  become  lodged  in  a  sacculation  and  be 
completely  arrested  above  the  superior  strait,  in  spite  of  the 
vigorous  contractions  of  the  uterus  lasting  for  hours  or  even  days. 
This  probably  occurs  only  in  muitiparse  :  the  cervical  canal  offers 
an  obstinate  resistance  to  the  dilating  force  for  twelve  or  even 
twenty-four  hours,  although  after  version  has  been  performed  it 
distends  readily  enough  ;  there  is  no  true  stricture  at  the  internal 
OS.  Even  during  the  expulsive  period  the  progress  of  labor  may 
be  arrested  if  the  os  fails  to  dilate  and  is  forced  down  into  the  inter- 
spinal line  by  the  pressure  of  the  head,  which  is  unable  to  perform 
complete  rotation.  This  complication  of  persistent  transverse  posi- 
tion of  the  head  is  partly  dependent  on  stenosis  or,  at  least,  rigidity 
of  the  lower  portions  of  the  birth-canal  and  is,  therefore,  particu- 
larly liable  to  occur  in  elderly  primiparse,  with  vaginismus  or  with 
coiling  of  the  umbilical  cord.  In  addition,  other  clonic  and 
tonic  muscular  spasms  (gastrocnemius)  and  frequent  reflex  attacks 
of  vomiting,  ptyalism,   hyperidrosis,  anidrosis,  severe  attacks  of 


ANOMALIES  IN  THE  LABOR-PAINS.  277 

migraine  and  neuralgia,  may  occur  during  pregnancy  and  labor. 
The  author  has  observed  a  whole  series  of  local  and  reflex 
nervous  symptoms  in  a  multipara  during  several  successive  de- 
liveries. During  the  height  of  the  labor-pains,  which  were  un- 
duly protracted,  clonic  fibrillar  contractions  of  the  extremities 
and  tic  convulsif  made  their  aj)pearance;  in  another  multipara 
the  labor-pains  during  several  deliveries  were  accompanied  by 
deep-seated,  continuous,  spasmodic  sacral  pains  and  by  stenocardia 
and  pain  in  the  subscapular  region.  Temporary  sciatica  and 
neuralgia  of  the  obturator  nerve  are  not  infrequent.  The  nervous 
symptoms  are  apt  to  be  exaggerated  during  influenza. 

On  the  other  hand,  labor-pains  may  come  to  a  complete  stand- 
still either  before  or  after  complete  dilatation  of  the  os,  especially 
after  premature  rupture  of  the  membranes.  A  concomitant 
symptom  is  "  atony  of  the  abdominal  pressure,"  which  is  partly 
dependent  on  hysterical  abulia. 

After  the  birth  of  the  child  we  often  observe  excessively  dis- 
tressing afterpains,  and  in  primipar^e  sometimes  a  constant  sore- 
ness of  the  coccyx  which  may  last  for  several  days.  In  the  third 
stage  irregular  pains  of  partially  tetanic  and  constricting  character 
lead  to  unequal  separation  of  the  placenta  or  to  its  retention 
within  the  body  of  the  uterus.  Excessive  afterpains  may  be 
hereditary  and  have  been  observed  to  occur  in  several  generations 
(Skutsch) ;  the  author  observed  a  case  of  this  kind  which  was 
associated  with  migraine. 

This  mixture  of  hyperesthesia,  atony,  and  partial  tetanic  phe- 
nomena extends  to  the  adjoining  organs,  as  the  bladder,  for 
instance.  Catheterization  during  labor  and  the  puerperium  is 
extremely  painful,  so  that  occasionally  ischuria  may  persist  an 
entire  week  in  spite  of  every  attempt  to  relieve  it  (hot  applica- 
tions and  douches,  psychical  suggestion),  and  in  the  absence  of 
all  objective  findings.  Similar  phenomena  come  to  the  notice  of 
the  gynecological  operator.  This  brings  us  very  near  the  domain 
of  disturbances  of  ithe  central  nervotis  system  which  may  lead  to 
psychoses  resembling  hysterical  manifestations. 

Multiparae  with  defective  innervation  of  the  abdominal  parietes 
and  of  the  pelvic  organs  often  suffer  from  Inchiometra  during  the 
first  days  of  the  puerperium  and,  occasionally,  from  fever  lasting 
twenty-four  hours  ;  the  amount  of  blood  and  secretion  discharged 
is  increased,  while,  on  the  other  hand,  the  milk  secretion  often 
fails  to  appear  or  disappears  suddenly,  and  the  abdomen  becomes 
swollen.  In  this  connection  we  must  also  refer  to  the  marked 
individual  variations  in  the  frequency  of  the  pulse  during  the 
puerperium. 

When  we  come  to  pathological  alterations  in  the  domain  of  the 
nervous  system  susceptible  of  objective  demonstration,  as  neu- 
ritis, multiple  neuritis,  and  myelitis,  etc.,  we  find  that  their  con- 


278  DIAGNOSIS  AND  TREATMENT. 

sequences  are  very  much  better  known.  In  myelitis  with  total 
loss  of  the  power  of  motion  and  sensation  in  the  lower  extremi- 
ties, the  complete  development  and  expulsion  of  the  fetus  have 
been  repeatedly  observed  without  the  occurrence  of  any  subjective 
sensation  of  pain  and  without  the  exertion  of  the  abdominal 
muscles,  and  this  also  has  been  frequently  confirmed  by  physio- 
logical experiments. 

The  clinical  picture  of  neuritis  gravidarum  and  puerperalis  is 
the  same  as  that  of  any  other  neuritis  :  complete  or  partial  loss 
of  motor-power  with  atrophy  of  the  muscles,  tenderness  of  the 
nerve-trunks  and  paresthesi^e,  especially  a  feeling  of  numbness  in 
the  fingers  and  toes  and  distressing  formication.  Occasionally 
multiple  neuritis  and  hyperemesis  make  their  appearance  toward 
the  end  of  pregnancy  in  combination  with  hemorrhages  from  the 
uterus.     The  possible  causes  are  : 

(a)  Mechanical  pressure  naturally  showing  itself  only  in  the 
lower  extremities  after  difiicult  extractions  ; 

{b)  Intoxications,  including  auto-  or  metabolic  intoxications, 
which  often  occur  during  pregnancy  and  may  be  associated  with 
hyperemesis,  and  infections  which  gradually  extend  to  all  the 
nerves  and  in  which  the  prognosis  is  very  unfavorable.  Possibly 
a  further  cause  may  be  found  in  the  excessive  use  of  disinfectants. 
The  treatment  consists  in  baths  and  massage  during  gestation, 
and  in  electricity,  but  only  during  the  puerperium.  Windscheid 
even  goes  so  far  as  to  suggest  the  induction  of  premature  labor  in 
severe  cases.  The  same  rules  of  treatment  apply  as  in  hyper- 
emesis. 


CHAPTER   YIII. 

GENERAL    REMARKS    ON    EXPLORATION    FOR 
PURPOSES  OF  DIAGNOSIS  AND  TREATMENT. 

A  SCHEME  of  the  various  dangers  to  mother  and  child  during 
labor  constituting  an  indication  for  operative  interference  has 
been  given  in  |  23. 

The  general  rules  to  be  observed  in  preparing  the  patient  are 
described  in  ^  2. 

?  24.  PREPARATION  OF  THE  PATIENT  FOR  EXAMINA- 
TION AND   INSTRUMENTAL  DELIVERY. 

If  the  physician  is  called  to  attend  a  labor  in  which  he 
has   any  reason    to    suspect    one    of  the  above-described 


PREPARATION  OF  THE  PATIENT.  279 

complications,  he  should  at  once  take  the  woman's  tem- 
perature. Meanwhile  he  should  make  his  inquiries  in 
regard  to  age,  the  possible  occurrence  of  rachitis  during 
infancy,  or  the  presence  of  any  other  organic  disease 
which  might  affect  labor,  the  course  of  former  deliveries, 
the  date  of  the  last  menstruation,  and  the  course  of  the 
labor  which  he  is  about  to  attend.  He  next  proceeds  to 
confirm  and  supplement  the  information  he  has  obtained 
by  means  of  objective  examination  (see  §  2),  paying  par- 
ticular attention  to  the  condition  of  the  bladder.  Internal 
examination  must  be  preceded  by  careful  disinfection, 
according  to  the  rules  given  in  §  2. 

In  the  mean  time  the  nurse  should  scrub  the  vulva, 
first  with  soap  and  then  with  a  1  per  cent,  lysol  or  3  per 
cent,  carbolic-acid  solution,  and,  if  necessary,  shave  the 
perineum  and  the  lower  half  of  the  labia,  and  evacuate 
the  rectum,  unless  it  has  been  previously  emptied.  This 
should  be  done  if  possible  with  the  woman  lying  cross- 
wise on  the  bed.  Next  the  catheter  is  introduced  and  the 
vagina  flushed  out  and  thoroughly  rubbed  w^ith  a  1  per 
cent,  solution  of  lysol  after  the  nurse  has  once  more  care- 
fully cleansed  her  fingers  with  a  brush.  The  cleansing 
of  the  vagina  may  be  omitted  unless  an  internal  examina- 
tion has  been  made  by  some  one  else  or  the  vaginal 
secretion  has  a  suspicious  odor  and  a  slightly  viscid  con- 
sistency. 

Instruments,  catheters,  glass  tubes,  etc;.,  are  to  be  care- 
fully boiled  and  then  placed  in  a  3  per  cent,  solution  of 
carbolic  acid.  Zweifel's  douche-bag  is  placed  in  the  same 
solution. 

The  following  articles  should  be  laid  out  in  readiness  :  Two 
basins  for  the  use  of  the  physician  to  wash  and  disinfect  himself, 
one  basin  with  carbolized  water  for  the  instruments,  one  vessel  to 
boil  the  instruments,  clean  towels  and  bed-sheets,  one  pail  and 
another  basin  or  other  vessel  instead  of  an  irrigator  for  the  douche- 
bag.     Every  receptacle  to  be  thoroughly  boiled. 

tJterine  irrigations  after  delivery  with  2  to  2J  per  cent,  carbolic- 
acid,  or  1  per  cent,  lysol  or  cresol  solution*,  are  performed  with  the 
aid  of  a  speculum  in  the  portio  vaginalis,  and  a  two-way  catheter 


280  DIAGNOSIS  AND  TREATMENT. 

(Fritsch-Bozeman).  They  are  to  be  practised,  however,  only  if 
the  possibility  of  infection  is  suspected  on  account  of  previous 
examination  or  of  operative  interference.  The  point  of  the  cath- 
eter is  guided  with  the  finger  until  the  fundus  is  reached — i.  e., 
beyond  the  contraction-ring,  which  must  be  carefully  felt  for. 
The  tube  of  the  catheter  should  not  contain  air,  but  should  be 
filled  with  sterile  water,  and  the  antiseptic  solution  is  not  to  be 
poured  in  until  the  operator  is  certain  that  a  continuous  flow  is 
established.  In  the  same  way  the  entrance  of  air  should  be 
guarded  against  at  the  end  of  the  irrigation. 

The  physician  now  makes  a  careful  examination  of  the 
pelvis,  ascertaining  its  form,  the  extensibility  of  the  soft 
parts,  especially  the  degree  of  dilatation  of  the  os,  the 
position  of  the  child,  and  the  progress  made  by  the  pre- 
senting part ;  for  instance,  in  what  diameter  of  the  pelvis 
the  sagittal  suture  is  found,  whether  the  anterior  or  poste- 
rior fontanel  is  deeper,  or  whether  there  is  a  presentation 
of  the  posterior  parietal  bone,  etc.,  and,  finally,  whether 
there  is  any  danger  for  mother  or  child  (see  §  23). 

So-called  diminution  in  the  force  of  the  labor-pains  is 
rarely  an  indication  for  the  use  of  forceps. 

We  have,  therefore,  three  questions  to  answer:  (1)  Is 
there  any  indication  for  interference  ?  (2)  What  operation 
is  indicated  ?  (3)  Has  the  proper  moment  arrived  ?  The 
proper  moment  is  determined  by  the  position  of  the  head 
and  the  degree  of  dilatation  of  the  os.  Internal  version, 
forceps,  and  craniotomy  require  a  dilatation  sufficient  to 
allow  the  passage  of  the  presenting  part,  and  if  that 
degree  of  dilatation  has  been  reached,  the  time  for  opera- 
tion has  come.  The  application  of  forceps  is  indicated  if 
the  head  is  firmly  fixed  ;  craniotomy  only  when  the  head 
has  descended  far  enough. 

All  operations  are  to  be  performed  with  the  most  scru- 
pulous antiseptic  precautions,  and  with  the  patient  lying 
crosswise  on  the  bed  with  the  legs  supported  on  two  chairs 
and  the  back  well  raised  by  means  of  pillows,  or  on  a 
table.  The  woman  is  placed  in  the  lateral  position  only 
when  version  is  to  be  performed,  on  the  side  corresponding 
to  the  position  of  the  feet.     If  the  woman  is  lying  on  her 


THE  INSTRUMENTARTUM. 


281 


left  side,  the  operator  uses  his  right  hand  for   internal 
manipulation,  introducing  it  at  the  end  of  a  labor-pain. 

The  chloroform  is  dropped  at  regular  intervals  on  the 
inhaler  until  narcosis  is  complete,  and  the  woman  is  then 
kept  on  the  boundary-line  between  anesthesia  and  con- 
sciousness. The  bladder  must  be  emptied  before  the 
beginning  of  the  operation. 


§  25.  THE  INSTRUMENTARIUM. 

The  instrument-bag  should  be  made  of  some  material 
which  can  be  readily  disinfected,  such  as  canvas  or  metal, 
and  contain  two  compartments^  one  of  which  {A),  also  made 
of  canvas,  contains  the  drugs  and  the  smaller  instruments, 
including  those  which  need  not  be  disinfected^  while  the 
other  (5),  which  can  be  sterilized,  being  made  of  metal  or 
linen,  after  Fritsch's  method,  contains  the  instruments 
which  require  sterilization. 


A  contains : 

Suturing  Apparatus. 

1.  Needles:  several  strong, 
curved  needles  in  a  tin  box. 

2.  Needle-holder. 

3.  Silk  sterilized  in  steam  and 
kept  in  envelopes  or  boiled  in  5  per 
cent,  solution  of  carbolic  acid  and 
kept  in  alcohol.  Silkworm  gut  in 
carbolic  acid. 

4.  Catgut  sterilized  by  dry  heat 
or  in  oil  of  juniper  and  kept  in 
alcohol. 

5.  Tenaculum  forceps. 

6.  Several  pairs  of  forceps  with 
a  sliding  catch  (Schroder). 

7.  Several  K5berle  forceps  or 
small  hemostatic  forceps  (Pean)  or 
clamp  force])S. 

8.  A  Dechamps  needle,  curved 
and  provided  with  a  handle. 

Sti rgical  Instruments . 

9.  Scalpel. 


11.  A  pair  of  Cowper's  curved 
scissors. 

12.  Apairof  long,  heavy  Siebold's 
scissors. 

13.  A  pair  of  forceps  1  foot  (30 
cm.)  long. 

14.  A  Cusco  or  Sims'  speculum. 

15.  A  curette. 

16.  A  razor. 

17.  Two  bullet  forceps. 

18.  Two  long,  heavy  hemostatic 
forceps  (clamp  forceps). 

Anesthetics. 

19.  4  tl.  oz.  (150  gm.)  chloroform 
in  a  dark  bottle. 

20.  An  Es march  inhaler. 

21.  A   pair  of  delicate   Muzeux 
forceps  or  other  tongue  forceps. 

Tamponade  and  Dilatation. 

22.  A  thin-walled  colpeurynter. 


10.  A     probe-pointed 
with  a  long  handle. 


bistoury 


23. 
cen  fc. 

24. 

25. 
ceps. 


Iodoform  gauze,  10  to  20  per 

Salicylated  cotton. 

A  pair  of  long  dressing  for- 


282 


DIAGNOSIS  AND  TREATMENT. 


Infusion. 

26.  A  heavy  infusion  needle  with 
rubber  tube  and  funnel,  or  a  syr- 
inge. 

27.  Several  packages  containing 
0.6  NaCl  or  Feis'  tablets. 

Antiseptic  Preparations. 

28.  Ih  oz.  (50  gm.)  liquid  carbolic 
acid  in  alcoholic  solution. 

29.  Twenty  tablets  0.5  sublimate 
(Angerer's  or  Pieverling's  hydrarg. 
oxycyanat.  tablets) ;  spiritus  vini 
rectif.  (alcohol). 

30.  1  oz.  (25  gm.)  lysol  for  1  per 
cent.  ly.sol  solution,  instead  of  vase- 
line. 

31.  A  glass  graduated  up  to  1  fl. 
oz.  (30  gm.). 

Various  Drugs. 

32.  Camphor. 

33.  2  fl.  oz.  (50  gm.)  aether,  sul. 

34.  Morphine  hydrochlorate  (3 
gr.  [0.2  gm.]  :  160  TT^  [10  gm.]  of 
water)  ;  syringeful  =  ^  gr.  (0.02 
gm.)  morphine  4- atropine. 

35.  +0Z.  (15  gm.)  chloral  hydrate, 
divided  into  ten  powders. 

36.  2  fl.  oz.  (50  gm.)  tincture  the- 
baica  (20  to  30  drops  a  dose). 

37.  Ergotin  or  cornutin. 

38.  2  per  cent,  solution  argentic 
nitrate. 

39.  2  fl.  oz.  (50  gm.)  liquor  ferri 
sesquichloridi. 

40.  Mustard  leaves. 

Various  Instruments,  etc. 

41.  Stethoscope. 

42.  Thermometer. 

43.  Two  nail-brushes. 

44.  One  elastic  Charriere  cathe- 
ter, No.  12. 


45.  Eubber  apron. 

46.  Tape-measure. 

47.  Towel  and  soap. 

B  contains : 

Obstetrical  Instruments. 

1.  A  Nagele's  forceps. 

2.  Cranioclast  or  cepnalotribe. 

3.  A  Nagele's  perforator. 

4.  A  Mesnard-L.  Wiuckel's  bone 
forceps. 

5.  A  loop  of  wide,  heavy  silk 
tape  (round  cord,  after  Ziegen- 
speck,  is  the  best). 

Irrigation,  Injection,  and  Catlieteri- 
zation. 

6.  Irrigator  with  rubber  tube  or 
Zweifel's  douche-bag. 

7.  Eectal  tube. 

8.  Vaginal  tube  of  glass  with 
slight  curvature. 

9.  Fritsch-Bozeman's  uterine 
catheter  of  large  caliber. 

10.  Two  medium-sized  elastic 
male  catheters  (Nos.  9  and  10). 

11.  A  silver  female  catheter. 

12.  A  Pravaz  syringe. 

Between  these  two  compart- 
ments, that  is  to  say,  in  the  body 
of  the  bag  itself,  a  Baudelocque- 
Martin's  pelvimeter  is  stowed  (see 
Fig.  43),  or  a  Gomann's  collapsible 
pelvimeter.  If  necessary,  the  large 
cranioclast  and  the  cephalotribe 
may  also  be  placed  in  this  part  of 
the  bag. 

Prussian^  midwives  must  have 
the  following  articles  in  their  bags 
in  addition  to  their  personal  toilet 
articles : 

An  instrument-ease  with  1,  3  oz. 
(90  gm.)  liquid  carbolic  acid  ;  2,  a 
graduated  glass  to  measure  i  oz. 


^  The  bag  of  the  Bavarian  midwife  contains  in  addition  a  second  vagi- 
nal glass  tube,  a  rectal  tube  made  of  hard  rubber,  a  medium-size  rectal 
syringe,  an  elastic  female  catheter,  a  rubber  nipple  with  a  glass  base,  1 
oz.  (30  gm.)  of  ether,  tincture  of  cinnamon,  oil  of  almonds,  a  fillet  for 
performing  version,  tampons  of  salicylated  cotton  in  bulk.  On  the  other 
hand,  it  does  not  contain  soap  and  towel,  a  metal  rectal  tube,  Hoffman's 
anodyne  drops,  and  silver-nitrate  solution. 


PUERPERAL  FEVER. 


283 


and  1  oz.  (15  aud  30  gm.)  carbolic 
acid;  3,  soap,  nail-biusli,  aud 
towel ;  4,  an  irrigator  of  one  quart 
(liter)  capacity  with  a  mark  at  1 
pint  (h  liter)  and  provided  witii  a 
rubber  tube  from  1  to  1|  yds.  (1  to 
1.5  meters)  loug ;  5,  a  glass  tube 
for  the  vagiua;  6,  a  metal  rectal 
tube  ;  7,  a  metal  female  catheter  ; 
8,  a  cord  cutter  ;  9,  a  narrow  lineu 
tape  ^  in.  (0.5  cm.)  wide  for  tying 
the  umbilical  cord  ;  10,  a  package 
with  twelve  balls  of  clean  cotton, 
the  size  of  a  lien's  agg,  tied  with  a 
thread    aud    preserved    in    white 


parchment  paper  and  the  whole  iu 
a  bag  of  some  white  material ;  11, 
vaseline;  l:i,  Hoffman's  anodyne; 
13,  dark  glass  medicine-dropper 
with  2  per  cent,  argentic  nitrate 
solution;  14,  clinical  thermome- 
ter ;  15,  bath-thermometer.' 

The  instruments  are  sterilized 
before  and  after  use  by  boiling 
them  for  from  fifteen  to  thirty 
minutes  in  a  3  per  cent,  carbolic- 
acid  solution,  or  they  may  be  ster- 
ilized by  dry  heat  up  to  302°  to 
338°  F.  (150°  to  170°  C). 


CHAPTER   IX. 


PATHOLOGY  OF   THE   PUERPERIUM. 
§  26.  PUERPERAL  FEVER. 


Owing  to  the  peculiar  mode  of  introduction  and  propagation 
of  micro-org-anisms,  puerperal  infections  present  certain  charac- 
teristic clinical  pictures  which  depend  on  alterations  in  the  cir- 
culatory apparatus,  on  the  presence  of  definite  lesions,  and  of 
typical  physiological  wounds  and  their  secretions.  These  clinical 
pictures  are  very  complex  and  their  classification  from  either  the 
anatomical  or  the  bacteriological  standpoint  is  somewhat  difiicult. 
While  giving  the  usual  scheme  of  classification,  I  shall  confine 
myself  in  the  text  to  the  description  of  the  clinical  pictures  which 
are  most  commonly  observed  at  the  bedside. 

The  cause  of  puerperal  fever  is  found  in  the  invasion  of  the 
excoriated  cavities  of  the  genitalia  by  pathogenic  bacteria, 
although  other  predisposing  causes,  such  as  cold,  dietetic  errors, 
emotional  excitement,  and  hemorrhage  may  indirectly  assist  the 
invasion  and  extension  of  the  micro-organisms  by  diminishing 
the  resisting-power  of  the  body. 

^It  is  often  important  for  the  physician  to  know  what  he  can  find  in 
case  of  necessity  in  a  midwife's  bag,  but  it  is  to  be  remembered  that  any 
operator  who  really  desires  strict  antisepsis  will  often  be  very  skeptical 
as  to  the  condition  of  the  contents  of  such  a  bag,  especially  as  the  mid- 
wife is  required  to  supply  the  materials  herself  in  pauper  practice.  In 
Baden  a  law  has  recently  been  passed  which  requires  midwives  to  get 
all  their  drugs  and  tampon  material  from  the  drug-stores. 


284     PATHOLOGY  OF  THE  PUEBPEBIUM. 

Anatomical  Classification. 

(1)  Ulcers  on  the  vulva,  vagina,  and  portio  vaginalis. 

(2)  Vulvitis,  colpitis,  acute  simple  endometritis. 

(3)  Acute  metritis  and  salpingitis. 

(4)  Paracolpitis  and  parametritis,  pelvicellulitis. 

(5)  Perimetrosalpingitis,  peritonitis. 

(6)  Phlebitis,  metrophlebothrornbosis. 

Bacteriological   Classification. 

(1)  Pyogenic  organisms  in  the  secretions  of  the  uterine  cavity. 

(2)  Micro-organisms  are  found  on  the  excoriated  surfaces 
(grayish  ulcers). 

(3)  The  micro-organisms  are  found  in  the  mucous  membrane. 

(4)  The  micro-organisms  penetrate  through  the  deeper  lym- 
phatic vessels  into  the  connective  tissue  (parametritis). 

(5)  Infection  of  the  tube  or  of  the  peritoneum  through  the 
same  channels  (peritonitis). 

(6)  The  micro-organisms  themselves  find  their  way  into  the 
circulation  and  spread  to  the  entire   body  (general  septicemia). 

(7)  The  products  of  the  micro-organisms  (sepsins  and  ptomaius), 
especially  of  the  microbes  of  putrefaction,  find  their  way  into  the 
vascular  channels  (sapremia). 

(8)  Infection  of  the  venous  thrombi  with  secondary  pyemic 
emboli  in  the  circulation  (pyemia). 

(9)  The  principal  bacteria  concerned  in  these  various  forms  of 
disease  are  the  Streptococcus  pyogenes.  Staphylococcus  aureus 
and  albus,  Bacterium  coli,  the  pneumococcus  and  gonococcus, 
the  tetanus  bacillus,  and  saprophytes. 

CliniGally,  we  distinguish  the  following  conditions  : 

(1)  Ulcers  of  the  vulva,  vagina,  and  ])ortio  vaginalis. 

(2)  Acute  simple  puerperal  colpitis  and  endometritis. 

(3)  Metritis  and  parametritis  (paracolpitis). 

(4)  Metrolymphangitis,  or  salpingitis,  and  peritonitis. 

(5)  General  fulminating  puerperal  septicopyemia. 

(6)  Sapremia. 

(7)  Metrophlebothrombosis  and  pyemia. 

(1)  Puerperal  Diphtheritic  Ulcers  of  the  Vulva,  "Vagina, 
and  Portio  Vaginalis. — Diagnosis. — The  ulcers  corre- 
spond in  position  with  the  sites  of  the  most  frequent 
lesions  during  labor,  i.  e.,  the  nymphse,  the  posterior  sur- 
face of  the  vestibule,  the  lower  portion  of  the  vagina,  the 
vaginal  vault,  and  the  external  os.     The  excoriations  and 


PUERPERAL  FEVER.  285 

fissures  begin  to  secrete  a  thin  pus  during  the  first  twenty- 
four  hours,  the  floor  of  the  ulcers  is  covered  with  a 
vellowish-o;rav  exudate,  and  the  edo-es  become  inflamed 
and  painful.  The  aflected  parts  are  edematous.  In  rare 
cases  a  phlegmonous  condition  develops  and  a  deep  ab- 
scess is  formed  in  the  connective  tissue.  Phlebectasia 
and  gonorrhea  are  predisposing  factors. 

Symptoms. — Pain  and  burning  sensation  during  micturi- 
tion, fetid  lochia,  remittent  fever  with  chills,  ischuria.  A 
careful  inspection  should  be  made. 

Treatment. — If  there  is  any  reason  to  suspect  puru- 
lent endometritis  before  labor,  the  vagina  should  at  once 
be  irrigated  with  a  3  per  cent,  solution  of  carbolic  acid 
or  a  1  per  cent,  solution  of  lysol  as  sl  prophylactic  measure. 
If  ulcers  are  present  they  must  be  touched  with  chloride 
of  zinc  or  ferric  chloride  and  dressed  with  itrol  (silver 
citrate)  or  iodoform  (iodoformogen  and  europhen),  or  com- 
presses of  aluminium  acetate,  or,  if  the  granulations  are 
flaccid,  the  old-fashioned  turpentine  dressing  may  be 
employed. 

(2)  Acute  Simple  Puerperal  Colpitis  and  Endometritis. — 
Diagnosis. — On  careful  examination  with  the  speculum 
the  papillae  on  the  vaginal  mucous  membrane  are  found 
to  be  very  prominent ;  the  entire  region  is  swollen,  red- 
dened, and  bleeds  on  the  lightest  touch.  The  lips  of  the 
external  os  are  swollen  and  edematous  and  covered  with 
exuberant  granulations  which  bleed  at  the  slightest  con- 
tact. The  portio  vaginalis  and  the  cervical  mucous  mem- 
brane, which  is  also  very  hyperemic  and  secretes  an 
abundant  mucopurulent  and  bloody  fluid,  are  covered 
partly  with  the  ovulse  Xabothi,  partly  with  prominent 
papules,  which  when  incised  are  found  to  contain  pus. 
In  the  rare  cases  that  come  to  the  autopsy-table  the  same 
condition  was  found  in  the  mucosa  of  the  body  of  the 
uterus,  especially  at  the  placental  site.  The  whole  mass 
of  swollen  mucous  membrane  can  be  readily  separated 
from  the  edematous  but  well-contracted  muscular  layer, 
and  is  found  to  be  full  of  ecchvmoses. 


286     PATHOLOOY  OF  THE  PUEBPERIUM. 

Symptoms, — The  lochia  are  often  fetid  and  streaked 
with  blood  ;  the  fever  is  quite  high  and  remittent  in  char- 
acter, short  chills  alternating  with  a  feeling  of  heat; 
afterpains  are  severe  and  persistent ;  the  uterus  is  slightly, 
the  abdomen  not  at  all,  sensitive.  Later  there  may  be 
hemorrhage  on  account  of  incomplete  involution  of  the 
placental  site,  and  the  condition  may  go  on  to  chronic 
endometritis  and  uterine  displacement. 

Etiology. — Injuries  ;  the  existence  of  catarrh  previous  to 
gestation  ;  faulty  aseptic  technique  in  suh-partu  explora- 
tions ;  decomposing  })orti()ns  of  the  fetal  membranes. 

Prognosis. — The  fever  lasts  from  three  days  to  a  week 
with  a  tendency  to  relapses.  The  inflammation  is  apt 
to  become  chronic  and  there  is  danger  of  extension  to 
deeper  tissues  or  to  the  tube  and  the  perimetrium.  The 
condition  is  often  complicated  with  subinvolution  of  the 
uterus,  and  may  be  followed  by  a  whole  series  of  gyne- 
cological troubles. 

The  course,  as  in  all  these  diseases,  depends  on  the 
virulence  of  the  micro-organisms  and  the  resisting-power 
of  the  genitalia  and  of  the  entire  body  to  the  action  of 
bacteria. 

Treatment. — Priessnitz  compresses;  ergotin  ;  vaginal 
irrigation,  repeated  several  times  a  day ;  mild  laxatives 
(calomel  gr.  ss  to  iss  [0.03  to  0.1  gm.]  three  or  four  times 
a  day).  If  the  hard  and  painful  condition  of  the  uterus 
persists,  vaginal  irrigations ;  intra-uterine  douche,  once 
repeated,  with  weak  antiseptic  solutions  (not  with  subli- 
mate) ;  or  cauterization  with  concentrated  carbolic  acid. 

(3)  Acute  Puerperal  Metritis  and  Parametritis  (Paracol- 
pitis).— By  metritis  is  meant  an  inflammation  of  the  peri- 
vascular and  interstitial  connective  tissue  of  the  muscu- 
laris,  originating  in  excoriations  or  ulcers  in  the  uterine 
cavity,  and  directly  caused  by  the  Streptococcus  pyogenes. 
The  inflammatory  process  spreads  to  the  connective  tissue 
outside  of  the  uterus,  and  from  that  point  successively 
involves  the  tissues  by  the  side  of  the  bladder  and  the 
extraperitoneal  connective  tissue  in  the  abdominal  walls, 


PUERPERAL  FEVER.  287 

or  even  of  the  upper  part  of  the  thigh,  or  it  may  spread 
laterally  between  the  two  layers  of  tiie  broad  ligament  to 
the  iliac  bones,  or  extend  backward  behind  the  peritoneum, 
pushing  up  Douglas'  pouch  and  involving  the  psoas 
muscles  or  even  the  kidneys. 

These  processes  are  included  under  the  terms  jxtra- 
mctritis  (Virchow)  or  i^ehio  cellulitis  (phlegmon  of  the 
pelvis,  pelvic  exudate),  and  consist  in  a  gelatinous  swell- 
ing and  round-celled  infiltration  of  the  connective  tissue 
(see  illustration  in  Atlas  of  Gynecology).  A  mass  of  exu- 
date which  often  attains  the  size  of  a  man's  head  grad- 
ually accumulates,  usually  to  one  side  of  the  uterus  and 
later  slowly  undergoes  absorption,  leaving  firm  indura- 
tions in  the  parametric  connective  tissue,  which  later  pro- 
duce pathological  fixations  and  displacements  of  the 
organ.  AYhile  this  is  the  usual  course,  the  exudate  may 
break  down  and  the  pus  may  be  discharged  into  the 
rectum,  into  the  vagina,  into  the  bladder,  through  the 
ischiatic  foramen  along  the  inguinal  canal,  or  directly 
through  the  abdominal  wall  above  Pou part's  ligament. 
Recovery  then  takes  place  unless  the  peritoneum  has 
given  way,  in  which  case  fatal  peritonitis  develops.  Oc- 
casionally the  process  involves  the  opposite  side  sec- 
ondarily. 

Symptoms. — During  the  first  week  after  labor  there 
is  generally  considerable  fever  with  chills  and  abdominal 
pain.  In  a  few  days,  as  the  exudate  accumulates,  the 
patient  complains  of  pain  in  the  loins  and  kidneys  and 
of  pain  and  loss  of  power  in  the  leg ;  urinary  symptoms 
are  sometimes  present  (paracystitis).  The  lochia  are 
often  fetid  and  may  become  bloody  again  owing  to  the 
subinvolution  of  the  uterus.  The  fever  gradually  as- 
sumes a  remittent  and  then  an  intermittent  type  Avith 
frequent  relapses.  If  the  fever  becomes  hectic  and  fre- 
quent chills  take  place,  it  is  a  sign  of  abscess-formation  ; 
as  soon  as  perforation  occurs  the  fever  disappears. 

Diagnosis. — As  soon  as  fever  and  pain  make  their  ap- 
pearance the  sensitiveness  of  the  abdomen  and  the  con- 


288     PATHOLOGY  OF  THE  PUERPERIUM. 

dition  of  the  lochia  must  be  carefully  examined.  The 
pain  in  the  abdomen  may  be  circumscribed  if  there  is  a 
local  irritation  of  the  serous  membrane,  but  the  entire 
surface  of  the  abdomen  is  never  jjainful  and  tumid  nor 
is  there  any  peritoneal  exudation.  On  the  other  hand,  it 
is  often  possible  from  the  very  first  to  detect  an  area  of 
tenderness  and  later  of  resistance  to  one  side  of  the 
uterus,  until  finally  a  tumor  of  doughy  consistency  is  dis- 
tinctly palpated.  The  vaginal  vaults  and  the  portio 
vaginalis  become  obliterated. 

The  diagnosis  is  somewhat  simplified  by  the 'fact  that 
the  exudate  does  not  spread  along  the  peritoneum,  but 
downward  along  the  vagina  or  to  Poupart's  ligament. 
For  the  differential  diagnosis  from  tumors  in  the  pouch 
of  Douglas,  see  under  Ovarian  Cysts,  Extra-uterine  Preg- 
nancy, Myomata. 

Prognosis. — The  prognosis  is  rarely  unfavorable  as  to 
life,  although  from  six  to  eight  weeks  usually  elapse  be- 
fore the  woman  recovers.  If  an  abscess  forms,  as  happens 
in  about  15  per  cent,  of  all  cases,  the  pain  is  intense  and, 
owing  to  the  severity  of  the  fever,  loss  of  strength  is  ex- 
treme and  convalescence  very  slow.  If  the  woman  is 
delicate,  it  is  better  to  tell  the  family  at  once  that  the 
patient  will  probably  have  to  be  confined  to  her  bed  for 
months. 

Treatment. — If  the  abdomen  is  very  painfid,  ice-bags, 
Priessnitz  compresses.  Absolute  rest  in  the  dorsal  posi- 
tion. Enemata;  calomel  several  times  a  day,  from  gr. 
viij  to  xxiv  (0.5  to  1.5  gm.) ;  castor  oil.  To  promote 
absorption  :  inunctions  with  mercurial  ointment,  gr.  xv 
(1  gm.)  of  the  ointment  mixed  with  an  equal  amount  of 
vaseline  every  two  hours  until  salivation  is  produced,  or 
potassium-iodide  ointment  may  be  substituted.  The 
fetid  lochial  discharges  and  the  ulcers  on  the  vulva  or 
portio  vaginalis,  if  any  are  present,  are  to  be  treated  in 
accordance  with  the  principles  laid  down  under  acute 
endometritis.  Fluctuating  abscesses  in  the  abdominal 
wall,  in  the  vagina,  or  in  the  rectum   should  be  opened  ; 


PUERPERAL  FEVER.  289 

in  the  latter,  with  the  aid  of  a  trocar.  In  addition  kike- 
warin  or  warm  baths  should  be  given  ;  the  diet  should 
be  light  but  nutritious.  If  there  is  diarrhea,  bismuth 
subnitrate  and  morphine  or  thebaine  are  indicated  ;  the 
last-mentioned  drug  has  a  certain  bactericidal  action. 

(4)  Septic  Metrolymphangitis.  Acute  Puerperal  Salpin- 
gitis and  Peritonitis. — In  nearly  all  the  cases  the  strepto- 
cocci effect  an  entrance  through  grayish-yellow  fissures 
and  ulcers  in  the  genital  tract  and  in  the  placental  site. 
The  infection  is  usually  unilateral  and  extends  from  the 
ulcerated  endometrium  through  the  swollen  lymph-chan- 
nels and  enlarged  and  suppurating  lymphatic  glands  into 
the  muscularis  and  thence  into  the  subserous  tissue.  The 
affected  tissues  rapidly  break  down  and,  along  with  the 
most  prominent  portion  of  the  serous  membrane,  become 
necrotic,  thus  leading  to  peritonitis.  The  serous  mem- 
brane is  the  seat  of  inflammatory  hyperemia.  The  true 
pelvis  is  filled  with  masses  of  exudate  ;  the  boAvels  are 
filled  with  gas,  and  loops  of  intestine  become  matted  to- 
gether. The  fluid  exudate  may  spread  beyond  the  cul- 
de-sac  of  Douglas  ;  and  gradually  all  the  various  organs 
of  the  body  become  involved  in  the  infectious  process : 
pleuritis  and  pericarditis  develop.  Occasionally  the  proc- 
ess remains  localized  near  the  spot  Avhere  rupture  of  the 
peritoneinn  first  took  place,  which  is  usually  in  Douglas' 
pouch  (circumscribed  peritonitis). 

The  virus  also  makes  its  -way  through  the  lymphatic 
channels  to  the  ovaries,  the  walls  of  the  tube,  and  the 
bladder,  so  that  abscesses  form  in  these  localities.  Rupt- 
ure of  an  ovarian  abscess  may  in  this  way  give  rise  to 
peritonitis. 

Finally,  the  virus  may  be  conveyed  to  the  peritoneum 
along  an  inflamed  Fallopian  tube — i.  e.^  by  an  endosal- 
pingitis,  the  pus  making  its  way  into  the  abdominal 
cavity,  usually  on  both  sides :  pelveoperitonitis.  If,  as 
sometimes  happens,  the  abdominal  opening  of  the  tube  is 
closed  by  adhesions,  a  pus-tube  may  form  and  rupture 
later  on. 

19 


290  PATHOLOGY  OF  THE  PUERPERIUM. 

Symptoms. — The  condition  begins  with  a  violent,  pro- 
tracted chill,  which  is  soon  followed  by  intense  pain  over 
the  entire  abdomen,  elicited  by  movement,  respiration,  and 
by  palpation,  especially  of  the  uterus,  which  is  hard  and 
enlarged.  The  congestion  in  the  vessels  of  the  head  shows 
itself  in  flushing  of  the  face  and  vertigo  ;  later  somnolence 
and  delirium  make  their  appearance,  and  may  even  go  on 
to  mania. 

There  is  a  rapid  rise  in  the  temperature  accompanied 
by  considerable  acceleration  of  the  pulse  and  of  respira- 
tion. The  presence  of  an  exudate  in  the  peritoneal  cavity 
can  often  be  detected  by  percussion  as  early  as  the  first 
day.  The  abdomen  is  tympanitic  and  very  much  swollen 
on  account  of  the  great  accumulation  of  gas  in  the  intes- 
tines, due  partly  to  the  paralyzing  effect  of  the  fever  on 
the  muscular  wall  and  partly  to  the  intestinal  inflamma- 
tion. Tenesmus  and  vomiting  also  occur,  as  pressure  is 
exerted  on  the  diaphragm  as  well  as  on  the  abdominal 
walls ;  dyspnea  soon  develops  and  later  becomes  more 
marked  as  the  pleura  participates  in  the  inflammation. 

The  secretions  of  the  body  are  diminished  in  quantity  ; 
there  is  vesical  tenesmus  and  the  urine  is  concentrated  and 
of  high  specific  gravity.  It  may  contain  albumin.  At 
first  there  is  constipation,  which  later  is  followed  by  diar- 
rhea. The  lochia,  which  are  also  diminished  in  quantity, 
have  a  fetid  odor  and  contain  many  pyogenic  cocci,  found 
in  the  decidua  cells  and  in  the  blood-corpuscles.  The 
milk  secretion  is  also  diminished  in  quantity. 

If  the  lymphatic  septic  peritonitis  runs  this  aaute 
course,  the  crisis  may  occur  within  eight  days  and  con- 
valescence gradually  begin,  or  the  patient  succumbs  to 
the  exhaustion.  If  the  exudate  is  not  absorbed  and  the 
patient  lives,  perforation  of  one  of  the  hollow  organs  or 
of  the  parietal  walls  may  take  place,  and  the  exudate  be 
discharged  ;  in  this  event  secondary  sloughing  of  intes- 
tinal origin  may  occur. 

Circumscribed  peritonitis  runs  a  chronic  course.  The 
disease  in  the  serous  membrane  progresses  slowly,  being 


PUERPERAL  FEVER.  291 

constantly  shut  off  from  the  rest  of  the  peritoneal  cavity 
by  the  formation  of  adhesions,  jUvSt  as  in  ovarian  abscess. 
This  form  of  peritonitis  is  described  as  pyofibrinous.  It 
leads  to  pathological  fixations  and  displacements  of  the 
uterus  and  to  chronic  inflammatory  processes. 

Diagnosis. — The  presence  of  an  intraperitoneal  exu- 
date is  determined  by  percussion  and  rectal  palpation,  the 
diagnosis  being  confirmed  by  the  existence  of  tenderness 
and  swelling  of  the  abdomen.  The  rupture  of  an  abscess 
is  detected  by  examining  the  urine,  feces,  etc. 

For  the  differential  diagnosis  from  parametritic  exudation  and 
retro-uterine  tumors,  see  under  Puerperal  Parametritis,  Ovarian 
Cysts,  etc. 

Treatment. — See  below. 

(e5)  Fulminating  Puerperal  Peritonitis.  Septicopyemia. — 
If  large  numbers  of  very  virulent  germs  suddenly  pene- 
trate into  the  peritoneal  cavity,  owing  to  rupture  of  the 
uterus,  rupture  of  a  pus-cavity,  or  the  discharge  of  septic 
pus  from  the  abdominal  orifice  of  a  tube,  the  course  is  so 
rapid  that  there  is  no  time  for  an  elevation  of  temperture  ; 
the  patient  immediately  goes  into  a  cachectic  state,  the 
pulse  and  respiration  are  enormously  accelerated  while  the 
temperature  falls.  The  symptoms  are  somnolence,  rapid 
swelling  of  the  abdomen  with  an  enormous  amount  of 
exudation,  pain,  singultus,  vomiting,  diarrhea,  and  invol- 
untary passage  of  urine  and  feces.  The  expression  of  the 
face  is  that  of  approaching  dissolution,  although  the  mind 
may  remain  clear  and  the  patient  be  cheerful  to  the  end. 
Death  almost  always  occurs  in  from  twelve  to  forty-eight 
hours.     For  the  treatment  see  below. 

(6)  Gangrenous  Peritonitis.  Sapremia. — If,  as  a  result 
of  pressure-necrosis,  a  part  of  the  uterus  or  of  the  fetus 
becomes  gangrenous,  or  rupture  takes  place  from  an 
encapsulated  focus  of  decomposition  or  from  the  intestine, 
the  entire  peritoneum  breaks  down  into  a  brow^nish  semi- 
fluid mass. 

Symptoms. — Rapid  development  of  meteorism,  high 
fever,  and  somnolence.     The  condition  usually  follows  a 


292     PATHOLOGY  OF  THE  PUERPERIUM. 

severe  spontaneous  or  instrumental  delivery  complicated 
by  localized  pressure-necrosis. 


TREATMENT  OF  ACUTE  PELVEOPERITONITIS  (METRO- 
LYMPHANGITIS  AND  SALPINGITIS). 

As  soon  as  tenderness  develops  in  the  abdomen  and  the 
intestines  become  distended,  a  Priessnitz  compress  should 
be  applied.  Calomel,  g\\  iss  to  v  (0.1  to  0.3  gm.),  and 
rectal  enemata  with  vaginal  and  intra-uterine  irrigations 
are  indicated.  The  latter  are  to  be  avoided  in  salpingitis, 
lest  tubal  contractions  be  induced.  If  ulcers  are  present 
they  should  be  cauterized. 

If  there  are  marked  symptoms  of  peritonitis,  such  as 
increase  in  the  exudate  or  excessive  tenderness  and  vomit- 
ing, several  ice-bags  should  be  applied  to  the  abdomen  as 
long  as  the  fever  lasts.  At  first  laxatives  may  be  given,  such 
as  inf.  sennse  comp.  and  calomel  (at  first  gr.  iij  to  viij  [0.2 
to  0.5  gm.],  later  gr.  |-  to  iss  [0.05  to  0.1  gm.]  at  a  dose). 
For  meteorism,  fennel,  hydrochloric  acid,  or  sulphur 
internally,  or  oil  of  turpentine,  ^ss  to  j  (15  to  30  gm.), 
per  rectum.  Profuse  diarrhea  may  be  checked  with  small 
doses  of  tincture  of  thebaine.  To  combat  the  vomiting, 
ice-pills  and  rectal  infusions  of  normal  salt  solution.  The 
diet  should  be  liquid  or  semisolid :  soup,  milk,  eggs, 
calves'-foot  jelly,  scraped  meat,  the  various  peptones  and 
hemoglobin  preparations,  beef-tea. 

The  patient  must  be  freely  stimulated  with  brandy, 
egg-no^,  champagne,  claret  (Runge  gives  large  doses : 
ffv  [150  gm.]  cognac,  half  a  bottle  of  claret  per  day),  in 
order  to  guard  against  excessive  loss  of  strength  and 
cardiac  failure,  but  only  when  the  patient  is  used  to  wine 
and  beer.  Other  stimulants  may  also  be  given,  such  as 
camphor  internally  and  hypodermatically,  ether,  bouillon. 
Diaphoresis  should  be  promoted,  and  infusions  of  deci- 
normal  salt  solution  administered. 

For  pleuritis  a  mustard-plaster  and  dry  cupping ;  for 
exhausting  diarrhea,  chlorine- water  in  an  equal  quantity 


TREATMENT  OF  SEPTICEMIA  AND  SAPREMIA.    293 

of  distilled  water,  one  tablespoonful  every  two  hours,  and 
emollient  beverages. 

It*  the  peritonitis  is  due  to  rupture  of  the  uterus  or 
vagina,  the  fetal  portions  that  have  escaped  are  to  be 
removed  and  the  wound  drained  with  iodoform  gauze.  In 
this  case  opium  may  be  employed. 

If  it  is  desired  to  supplement  the  administration  of 
calomel  by  a  general  mercurial  treatment,  sij  (8  gm.)  of 
blue  ointment  mixed  with  an  equal  quantity  of  vaseline 
may  be  rubbed  in  every  day  until  salivation  is  produced 
(gr.  XV  [1  gm.],  every  two  hours  for  about  a  week).  The 
same  effect  may  be  produced  by  the  inunction  of  the  silver 
salts  in  the  form  of  ointments  (Crede). 

In  the  lymphatic  form  diaphoretic  remedies  may  be 
employed  with  good  results  (Kehrer)  :  aromatic  tea  with 
warm  pack,  camphor  and  liquor  ammonii  acetatis  (the 
kidneys  must  be  watched)  with  morphine  and  small  doses 
of  quinine  or  lukewarm  baths;  this  must  also  be  supple- 
mented by  alcoholic  stimulation  and  nutritious  diet.  As 
soon  as  fluctuation  is  detected,  and  the  wall  of  the  vagina 
or  of  the  abdomen  begins  to  bulge,  the  abscess  should  be 
opened  and  drained  with  iodoform  gauze. 

TREATMENT  OF  GENERAL  SEPTICEMIA  AND 
SAPREMIA. 

The  treatment  of  septicemia  consists  in  encouraging 
diaphoresis  bv  means  of  baths  at  a  temperature  of  from 
80°  to  88°  1^(26.6°  to  31.1°  C).  The  bath  should  last 
not  longer  than  five  minutes,  the  patient  being  carefully 
watched  and  stimulated  with  alcoholic  beverages  during 
and  after  the  bath,  as  directed  above.  The  food  should 
be  rich  in  albumin  and  easily  digestible ;  ice  and  refresh- 
ing and  cooling  drinks  should  be  given  freeh\  In  addi- 
tion, decinormal  saline  solution  should  be  injected.  In 
sapremia  the  first  thing  to  be  done  is  to  remove  the  focus 
of  decomposition,  the  dead  fetus  or  fetal  remains,  but 
without  producing  any  new  lesions.  Before  and  after  the 
operation  the  uterus  should  be  irrigated  with  3  per  cent. 


294     PATHOLOGY  OF  THE  PUERPERIUM. 

carbolic-acid  or  1  per  cent,  lysol  solutions,  or  the  uterine 
wall  cauterized  with  concentrated  carbolic  acid.  After 
the  operation  is  completed,  iodoform  or  itrol  pencils  (silver 
citrate)  should  be  introduced  into  the  cavity,  or  the  entire 
uterus  packed  with  iodoform  or  itrol  gauze. 

(7)  Metrophlebothrombosis. — In  phlebothrombosis  the 
thrombi  which  normally  close  the  vessels  of  the  placental 
site  extend  into  the  veins  of  the  entire  uterine  wall  and 
even  as  far  as  the  internal  ovarian  veins,  from  which 
emboli  are  thrown  off  and  make  their  way  into  the  general 
circulation  and  into  all  the  organs,  especially  into  the 
lungs.  If  the  thrombi  undergo  decomposition  or  become 
infected  by  pathogenic  micro-organisms,  the  emboli  them- 
selves carry  the  infection  and  set  up  metastatic  abscesses 
wherever  they  go — in  the  spleen,  which  is  usually  enlarged, 
in  the  kidneys,  in  the  liver,  producing  intense  jaundice, 
and  especially  in  the  lungs,  joints,  eyes,  and  skin.  The 
condition  is  not  so  frequent  as  metrolymphangitis.  The 
peritoneum  and  pleura  are  not  rarely  affected. 

Symptoms  and  Diagnosis, — After  mild  symptoms  of 
endometritis,  or  even  quite  unexpectedly,  with  or  with- 
out pain  or  hemorrhage,  a  violent  chill  makes  its  appear- 
ance with  marked  rise  in  the  temperature  and  followed  by 
profuse  sweating.  There  is  great  tenderness  over  the 
uterus,  while  the  pain  in  the  abdomen  is  slight  and 
present  only  in  circumscribed  areas. 

These  attacks  of  metastatic  pyemia  occur  repeatedly, 
so  that  the  patient  rapidly  goes  into  a  state  of  collapse 
with  violent  headache  and  marked  precordial  oppression. 
Gradually  the  symptoms  of  the  individual  metastatic 
affections  make  their  appearance.  Death  usually  occurs 
after  two  or  three  weeks  of  violent  remittent  and  inter- 
mittent fever,  as  has  been  described.  Phlegmasia  alba, 
dolens,  which  is  not  very  dangerous  as  a  primary  condi- 
tion, often  occurs  secondarily  by  thrombosis  of  the  femoral 
veins,  and  manifests  itself  as  a  tense  whitish  swelling  of 
the  skin  covering  the  thighs. 

Treatment. — In  the  prophylaxis,  which  is  of  the  highest 


TREATMENT  OF  SEPTICEMIA  AND  SAPREMIA.    295 

importance,  several  sources  of  danger  must  be  carefully 
kept  in  view  : 

(1)  The  formation  of  large  thrombi  is  to  be  avoided  by 
removing  any  possible  cause  of  uterine  hemorrhage. 

Among  such  causes  we  have  : 

(1)  Insufficient  contraction — either  a  mere  irregularity  in  the 
contractions  of  the  uterine  muscle  without  marked  hemorrhages, 
or  paralyses  localized  at  the  placental  site  with  severe  and  dan- 
gerous metrorrhagia. 

(2)  The  retention  of  fetal  remains.  These  usually  lead  to 
hemorrhage  only  in  the  first  week,  but  they  may,  by  undergoing 
decomposition,  lead  to  putrefaction  of  the  thrombi  and  secondary 
hemorrhages. 

(3)  Atony  of  the  uterine  muscle,  especially  at  the  placental  site, 
due  to  subinvolution ;  this  usually  leads  to  slight  but  repeated 
hemorrhages  after  the  first  week. 

(4)  Endometritis,  which  is  often  the  primary  cause  of  the 
atony,  may  also  lead  to  putrefaction  of  the  thrombi  and  inflamma- 
tory hyperemia. 

(e5)  Venous  stasis ;  this  may  also  produce  hemorrhage  if  neigh- 
boring organs  are  engorged,  if  the  woman  is  allowed  to  get  up  too 
soon,  or  if  the  abdominal  muscles  are  unduly  exerted,  as  in 
straining  at  stool,  cough,  and  various  kinds  of  work,  if  the  circu- 
lation is  impeded  by  angulation  or  displacement  of  the  uterus. 

Emotional  excitement  and  sudden  attacks  of  fever  re-enforce 
these  predisposing  factors  by  the  acute  Ijyperemia  which  they 
occasion. 

(2)  The  decomposition  of  the  thrombi  is  to  be  avoided 
by  immediate  local  treatment  of  the  puerperal  endome- 
tritis. 

(3)  If  putrefaction  has  occurred,  measures  must  be 
adopted  to  check  its  progress  and  prevent  the  expulsion 
of  emboli  by  bringing  about  contraction  of  the  uterus,  dis- 
infecting the  lochia,  and  by  insisting  on  absolute  rest  in  bed 
in  the  dorsal  position,  forbidding  any  kind  of  movement, 
such  as  sitting  up  for  the  purpose  of  emptying  the  bowels, 
etc.,  and  combating  constipation,  ischuria,  and  bronchial 
catarrh. 

(4)  If,  in  spite  of  these  precautions,  emboli  are  formed, 
the  organism  must  be  brought  into  a  condition  to  neu- 
tralize  the  ptomains    by   feeding   the   patient  on   light, 


296     PATHOLOGY  OF  THE  PUERPERIUM. 

Fig.  159.  Puerperal  Diphtheritic  Endometritis  and  Colpitis.— The 
thrombi  at  the  placental  site  have  undergone  suppuration.  Case  of 
eclampsia  (original  water-color). 

digestible  diet  (every  two  hours)  and  by  supporting  the 
strength  with  cooling  drinks  and  alcoholic  stimulants,  as 
explained  in  a  preceding  paragraph  {q.  v.).  Alcohol  is 
indicated,  especially  in  cardiac  weakness,  which  should 
also  be  combated  by  injections  of  ether  and  camphor,  warm 
baths  or  warm  packs  after  Priessnitz  or  Jacquet;  for 
diaphoresis,  cold  sponging  and  douching. 

To  counteract  the  evil  effects  of  decomposition  of  the 
thrombus,  mercury,  and  possibly  also  the  silver  salts  in 
the  form  of  ointments  have  been  found  useful  (see  Treat- 
ment of  Metrolymphangitis). 

I  27.  INTERDEPENDENCE  BETWEEN  THE  PUERPERAL 
PROCESSES  AND  OTHER  DISEASES. 

In  the  paragraphs  on  Pregnancy  and  Labor  the  alarming  influ- 
ence of  certain  diseases  on  the  puerperium  was  mentioned  (see 
II 14  and  33).  The  febrile  infectious  diseases,  especially  erysipe- 
las, croupous  pneumonia,  and  influenza  must  be  regarded  as 
serious  complications  of  a  puerperium,  not  only  because  of  their 
effect  on  the  general  condition  but  also  on  account  of  the  dis- 
turbances in  the  pulmonary  circulation  to  which  they,  give  rise. 
The  existence  of  a  pseudoscarlatinoid  form  of  sepsis  has  been 
alluded  to  in  1 14.  Influenza  may  act  as  the  cause  of  the  endo-  or 
parametritis;  the  author  is  in  a  position  to  confirm  the  occur- 
rence of  excessively  painful  labor-pains  and  afterpains;  anom- 
alies in  the  lochial  discharges  which  are  reduced  in  quantity,  of 
a  purulent  consistency  and  brownish  color,  and  do  not  become 
fetid  until  the  third  or  fourth  day  ;  rise  in  temperature,  102.2°  to 
104°  F.  (39°  to  40°  C),  without  any  marked  acceleration  of  the 
pulse  (108  to  120)  ;  and  a  tendency  to  marked  diaphoresis,  vomit- 
ing, meteorism,  and  diarrhea  without  peritonitis.  Occasionally 
influenza  becomes  complicated  with  a  streptococcal  infection  of 
the  endometrium  and  the  disease  assumes  a  grave  septic  character. 

Treatment. — Diaphoresis ;  laxatives  ;  enemata,  and  rectal  and 
vaginal  irrigations  ;  Priessnitz  compresses  on  the  abdomen  and 
breast ;  sali^yrin  ;  very  light  diet,  frequently  administered  in 
small  quantities. 

Cardiac  disease  without  compensation  and  pulmonary  disease 
not  rarely  lead  to  pulmonary   edema  and  later  to  progressive 


72. 


Fig.  159. 


%.^ 


V 


■/,;,„/,;      \!i}viri>P!> 


PUERPERAL  PROCESSES  AND   OTHER  DISEASES.    297 

miliary  tuberculosis.  The  proper  treatment  should  be  instituted 
during  the  puerperium  (see  H  14  and  23). 

Among  nervous  diseases  we  have  already  mentioned  the  occur- 
rence during  the  puerperium  of  psychoses,  which  may  or  may  not 
have  been  present  before,  especially  melancholia  with  secondary 
anemia  and  the  effects  of  chorea  and  myelitis.  The  prognosis  of 
a  psychosis  depends  on  whether  it  is  hereditary  or  not. 

Diseases  affecting  the  metabolism,  and  urinary  diseases,  includ- 
ing secondary  amaurosis,  are,  as  a  rule,  favorably  influenced  by 
the  puerperium.  Eclampsia  rarely  occurs  in  the  puerperium  and, 
if  it  does,  runs  a  milder  course;  but  this  is  not  the  case  if  the 
attacks  continue  after  the  expulsion  of  the  child.  Coma  is  occa- 
sionally followed  by  protracted  loss  of  memory,  by  psychoses,  and 
by  amaurosis. 

Tumors  of  the  genital  tract  may  become  daDgerons  in 
various  ways.  A  myoma  will  usually  undergo  involu- 
tion ;  but,  if  the  nutrition  is  disturbed,  it  may  degenerate 
or  decompose  and  produce  most  unfavorable  conditions. 
Ovarian  Gysts,  on  the  other  hand,  continue  to  grow  and, 
as  the  pedicle  is  apt  to  be  twisted  or  crushed,  necrosis  or 
decomposition  is  very  likely  to  result. 

Treatment. — Hemorrhages  due  to  myomata  are  to  be 
treated  during  and  after  labor  as  explained  in  §  23, 
No.  1,  and  later  on  in  the  puerperium  with  ergot  or 
ergotin.  Pedunculated  polypi  extending  into  the  cervix 
or  even  into  the  vagina  must  be  removed  immediately 
after  delivery  on  account  of  the  danger  of  gangrene. 
Other  tumors  which  are  not  readily  accessible  should  be 
let  alone. .  If  they  undergo  decomposition  they  must  be 
removed,  and  if  this  cannot  be  effected  through  the 
vagina,  a  celiotomy  is  to  be  performed,  followed  by  total 
extirpation  of  the  infected  uterus. 

If  ovarian  cysts  are  not  complicated  by  torsion  of  the 
pedicle  or  suppuration  or  sloughing,  nothing  should  be 
done  until  the  end  of  the  puerperium,  but  if  such  com- 
plications exist  ovariotomy  should  be  performed  at  once. 

There  is  a  wide  field  for  the  exercise  of  prophylaxis  in 
the  treatment  of  relaxed  conditions  of  the  abdominal  and 
pelvic  organs  due  to  loss  of  elasticity  and  tonus  in  the 
striated  and  unstriated  muscles,  including,  therefore,  the 


298 


PATHOLOGY  OF  THE  PUEEPERIUM. 


walls  of  the  vessels.  The  immediate  consequences  of  this 
condition  are  postpartum  hemorrhages  from  the  flaccid 
uterus,  which  is  usually  much  depressed  and  in  a  condi- 
tion of  retroversion.  During  the  puerperium  the  hemor- 
rhage manifests  itself  by  the  presence  of  blood  in  the 
lochial  discharges,  which  retain  their  hemorrhagic  char- 
acter and  become  profuse.  This  appears  to  indicate  a 
retention  of  the  secretions  in  the  relaxed  uterus,  a  condi- 
tion which  I  have  already  referred  to  under  the  name  of 


Fig.  19.— Abdominal  scar  after  an  operation  for  the  removal  of  an 
ovarian  cyst  in  the  fourth  month  of  prejjnancy.  Note  the  peculiar 
distribution  of  the  pigment,  corresponding  with  the  sutures  and  the 
scar  (from  a  case  of  the  author's  on  the  fourth  day  after  a  spontaneous 
delivery). 

lochiometra.  The  entire  abdomen  becomes  distended 
with  gas,  the  normal  functions  of  the  intestine  and  of  the 
bladder  are  practically  abolished  often  as  long  as  one  or  two 
weeks  after  delivery,  and  the  abdominal  muscles  become 
completely  relaxed.  Passive  congestion  in  the  entire  ab- 
dominal distribution  of  the  splanchnic  nerve  affects  the 


MAM3IARY  GLANDS  DURING  THE  PUERPERIUM.  299 

mammary  glands  to  such  an  extent  that  milk  secretion 
soon  ceases  or  may  even  fail  to  become  established. 

The  ultimate  result  of  neglecting  these  conditions  is 
permanent  agalactia,  distention  of  the  abdomen— often 
associated  with  dysmenorrhea  or  lasting  amenorrhea— 
backward  displacement  and  descent  of  the  uterus  with 
congestion  or  inflammation  and  gastro-enteroptosis. 

Treatment.— kh(\om\\r^i\  massage,  a  tight  binder  to  the 
abdomen,  ergotin,  the  introduction  of  a  pessary  about 
the  end  of  the  first  week,  with  proper  attention  to  the 
regulation  of  the  bowels  (after  the  second  day)  and  of  the 
bladder. 

1 28.  DISEASES  OF  THE  MAMMARY  GLANDS   DURING 
THE  PUERPERIUM. 

Inflammation  of  the  mammary  gland,  or  mastitis,  is  a 
tedious  and  more  or  less  serious,  but  rarely  a  fatal  disease. 
It  is  due  to  the  action  of  staphylococci  and  streptococci 
which  make  their  entrance  through  minute  solutions  of 
continuity  in  the  skin,  usually  fissures  about  the  nipple ; 
thecocci^are  also  found  in  the  ducts  of  the  gland,  but 
their  virulence  appears  to  be  much  attenuated.  Either 
they  establish  themselves  about  smaller  ducts  and  i«  the 
acini  and  set  up  inflammation  and  suppuration  in  them 
(parenchymatous  mastitis),  or  they  follow  the  course  ot 
the  interlobular  connective  tissue  (interstitial  mastitis)  or, 
finally,  a  retromammary  abscess  may  form.         ^ 

Symptoms.— ^ome  difficulty  is  experienced  m  finding 
the  fissures,  which  are  usually  hidden  in  the  minute  fur- 
rows between  the  glands  of  Montgomery.  Sometimes 
they  are  very  painful  and  are  then  found  to  be  ulcerated 
and  covered  with  an  exudate. 

From  these  excoriations  a  cord-like  wheal  extends  to 
the  nearest  lobule,  in  which  the  inflammatory  process 
manifests  itself  early  by  a  tense  hardness  and  increased 
sensitiveness  to  pressure.  The  surrounding  skin  becomes 
reddened  ;  later  edema  develops  and  indicates  the  forma- 


300  PATHOLOGY  OF  THE  PUERPERWM. 

tion  of  a  deep  al)scess.  This  is  soon  followed  either  by 
fluctuation  or  by  the  formation  of  minute  fistulse,  beneath 
which  there  is  an  extensive  suppuration.  Owing  to  the 
plentiful  supply  of  lymphatics  in  the  organ  the  fever  is 
very  high — 104°  F.  (40°  C.)  and  over  is  nothing  unusual. 
The  occurrence  of  suppuration  is  usually  preceded  by  a 
chill. 

The  individuals  most  predisposed  are,  of  course,  those 
of  weak  and  scrofulous  constitution,  and  the  suppuration 
in  these  cases  may,  in  spite  of  energetic  treatment,  gradu- 
ally extend  from  lobule  to  lobule  and  may  even  involve 
the  other  breast.  In  some  cases,  which  are  fortunately 
extremely  rare,  general  sepsis  develops. 

During  the  winter  of  1898  to  1899  I  observed  a  case  of  this  kind 
for  seven  weeks.  The  mother  was  young  and  in  very  delicate  health. 
There  were  old  scars  from  the  removal  of  lymphatic  glands  in  the 
neck.  The  woman  was  in  miserable  circumstances  and  had  been 
attacked  by  influenza  shortly  before  her  confinement.  In  spite  of 
ice-bags,  compresses,  and  early  incisions,  the  entire  glandular 
tissue  of  both  breasts  was  gradually  destroyed.  The  skin  was 
undermined  in  both  directions  by  small  fistulae,  while  several  deep 
abscesses,  varying  in  size  from  a  walnut  to  an  apple,  had  formed 
in  the  substance  of  the  gland.  It  was  evident  that  the  tissues  of 
the  glands  had  lost  all  their  bactericidal  power. 

Treatment. — The  fissures  about  the  nipple  should  be 
covered  with  cloths  wrung  out  in  aluminium  acetate  and 
the  breasts  emptied  with  a  glass  breast-pump,  which  may 
also  be  used  as  a  precautionary  measure  in  the  other  breast. 
The  plan  of  hardening  the  nipples  during  pregnancy  does 
not  recommend  itself  to  the  author  (see  §  10),  at  least, 
not  with  brandy ;  daily  washing  with  cold  water  or  30 
per  cent,  tincture  of  nut2:all  may,  however,  be  tried 
(Ahlfeld). 

If  inflammation  has  already  developed  in  the  surround- 
ing tissue,  the  affected  breast  should  be  allowed  to  rest  for 
a  few  days  and  dressed  with  compresses  wrung  out  in 
lead  acetate.  The  same  treatment  is  employed  if  one  of 
the  lobes  is  distinctly  hard.  Compresses  are  wa'ung  out 
in  lead-water  cooled  with  ice  and  changed  every  five  to 


MAMMARY  GLANDS  DURING    THE  PUERPERIUM.  301 

fifteen  minutes.  At  the  first  sign  of  suppuration,  such  as 
edema  of  the  skin,  that  is  to  say,  very  early,  the  breast  is 
incised  and  drained,  counter-drainage  being  established  if 
necessary,  and  the  wound  irrigated  through  and  through. 
Light,  nutritious  diet  should  be  ordered,  the  bowels  regu- 
lated, and  measures  adopted  to  promote  diaphoresis. 

Hypersecretion  of  the  mammary  glands  manifests  itself 
in  polygalactia,  i.  e.,  simple  hypersecretion,  and  in  galac- 
torrhea,  a  condition  in  which  the  milk  flows  in  an  unin- 
terrupted stream  ;  it  is  evidently  due  to  disturbance  of 
the  innervation.  The  symptoms  at  first  are  the  same  as 
those  which  attend  prolonged  lactation,  dragging  pains  in 
the  breast  and  back,  feeling  of  oppression  in  the  stomach, 
loss  of  appetite,  visual  disturbance,  chlorosis,  weakness. 
Before  long,  however,  the  symptoms  of  oligemia  become 
more  marked.  The  patient  complains  of  palpitation  of 
the  heart,  the  pulse  is  small  and  rapid,  oliguria,  convul- 
sions, and  attacks  of  syncope  make  their  appearance.  The 
treatment  consists  in  massage,  compression  by  means  of  a 
bandage,  iodine  and  sodium  iodide  internally. 


302 


PATHOLOGY  OF  THE  PUERPEBIUM. 


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EXPLANATORY  NOTE. 

Each  illustration  is  provided  with  a  description  found 
at  the  top  of  the  even  page,  above  the  main  text.  The 
reference  letters  and  numbers  in  the  descriptions  are  espe- 
cially chosen  for  each  illustration  ;  but  in  addition  to  these, 
another  set  of  numbers  has  been  used  in  the  description 
of  the  many  sagittal  sections  and  other  illustrations  of  the 
pelvis,  identical  with  the  numbers  used  in  the  Atlas  of 
Labor  and  Operative  Obstetrics.     They  are  the  following  : 


1,  Symphysis. 

27. 

Anterior  superior  spines. 

2.  Promontory. 

28. 

Ala  of  sacrum. 

2a.  Double  promontory. 

29. 

Sacro-iliac  articulation. 

3.  Coccyx. 

30. 

Ileopubic  tubercle. 

4.  Cervix. 

31. 

Acetabulum. 

4a.  External  os. 

32. 

Ueosacral    ligaments ;    poste- 

46.  Internal  os. 

rior 

superior  spines. 

5.  Bladder. 

33. 

Femur. 

6.  Vagina. 

34. 

Anterior  inferior  spines. 

7.  Kectum. 

35. 

Obturator  foramen. 

7a.  Anus. 

37. 

Ovary. 

8.  Walls  or  body  of  uterus. 

38. 

Oviduct  (tube). 

9.  Spines  of  the  ischium. 

39. 

Broad  ligament. 

10.  Tuberosities  of  the  ischium. 

40. 

1  Anterior      and      posterior 
]      sacro-iliac  ligaments. 

14.  Perineum. 

41. 

16.  Umbilical  cord. 

42. 

Eound  lieament. 

17.  Placenta. 

43. 

Ovarian  ligament. 

20.  Eima  pudendi. 

44. 

Sagittal  suture, 

21.  Lower  uterine  segment. 

45. 

Lesser  fontanel. 

26.  Tumor. 

306 


INDEX. 


Abdomen,  conical,  Pig.  127 

pendulous,  Figs.  99,  128,  129 
Abdominal  pregnancy,  195  ;   Fig. 

116 
Abortion,  31 

anomalies  that  lead  to,  IS-i 

at  end  of  second  month,  Fig.  8 

criminal,  167 

diagnosis,  134 

from  endometritis,  14-4 

from  subchorionic  hemorrhage, 
138,  141 

from  syphilis,  149 

treatment,  134 

with  hydatid  moles,  146 
Acantho}Delys.  242  ;  Fig.  148 
After-birth,  expulsion  of,  97 
After-pains,  excessive,  277 
Alexins,  bactericidal,  101 
Allantoic  sac,  22 
Amnion,  21 
Amniotic  fluid.  21 

sac.  28 
Ampulla  of  uterus,  20 
Anatomical  features  of  pregnancy 

in  each  month,  30 
Anemia  of  pregnancy.  163 
Anomalies  in  labor-pains,  268,  270 

of    fetal    membranes,    dTstocia 
from,  266 

of  genitals,  effect  on  pre2;nancv, 
168 

of  umbilical  cord,  dystocia  from, 
266 
Anteflexion  of  gravid  uterus,  174 
Anteroposterior  diameter  of  pelvic 

outlet,  51 
Anteversio  flexio  uteri,  175 
Arbor  vitae  uteri,  25 


Arteries  of  uterus.  26  ;  Fig.  31 
Artificial  feeding,  118 
Assimilation-pelves,  241 
Atony  of  uterine  muscle,  272 
Atresia  of  cervix,  dystocia  from, 
258 
of  hymen,  dystocia  from,  258 
of  vagina,  dystocia  from,  258 
Auscultation  in  diagnosis  of  preg- 
nancy. 37 

Bacteria  of  vagina,  103 
Bacterial  infection  in  labor,  101 
Basedow's  disease  and  pregnancy, 

163 
Baudelocque,  diameter  of,  51 
Biedert's  cream-mixture.  122 
Blastodermic  vesicle.  21 
Blastula,  21 

Bones  of  infant,  development,  110 
Brain  of  fetus,  morphology,  109 
Bruit,  uterine.  32 

Caxal  of  Xuck,  79 
Cancer  of  uterus,  189 
Carcinoma,  dystocia  from,  262 
Cardiac    insufficiency    and   labor. 

274 
Cattle,  importance  of.  120 
Cellulitis,  pelvic,  286 
Cephalic  presentation  in  flat  pel- 

yis,  Fig.  129 
Cervical  canal,  examination  of.  43 
Cervix,  lacerations  of,  252 

uteri,  25 
Cholera  and  pregnancy.  156.  164 
Chorion.  23 

epithelioma  of,  146 
Chorionic  villus,  Fig.  16 

'       307 


308 


INDEX. 


Circulation    in    new-born    infant, 

Circumference  of  pelvis,  51 
Classification  of  deformed  pelves, 

212 
Collapsed  pelves,  222 
Colostrum,  108 
Colostrum-cells,  Fig.  85 
Colostrum-corpuscles,*107 
Colpeurynter,  172 
Colpitis,  puerperal,  285 
Conception,  failure  of,  179 
Conduplicatio  corpore,  Fig.  57 
Conical  abdomen,  Fig.  127 
Conjugate,  diagonal,  53 
diameter,  55 
true,  53 
Contracted  pelvis,  Figs.  50,  120 

anteroposteriorly,  215 

generally,  212 

obliquely,  230 

transversely,  236 
Contraction-ring,  77 
Convulsive  labor-pains,  271 
Corpus  luteum,  19  ;  PL  1,  Fig.  2 
Crede's  method  of  expressing  pla- 
centa, 98 
Criminal  abortion,  167 
Cystic  enchondroma,  Fig.  150 
Cystocele,  dystocia  from,  259 

Decidua  cells,  27  ;  Fig.  15 
necrotic,  104 
polyposa,  145 
reflex  a,  23 
vera,  23  ;  Fig.  10 
Decidual  endometritis.  Fig.  90 
hemorrhages,     abortion     from, 
138 
Decubital  pelvis,  228  ;  Fig.  5 
Deformed  pelves,  209 ;  Pis.  25,  56, 

57 
Deformities  of  pelvis,   pregnancv 

and,  204 
Dembo's  ganglion,  73 
Dermoid    cysts    and     pregnancy, 

188 
Development  of  ovum,  15 
Deventer's  pelvis,  215 
Diabetes,  pregnancy  and,  163 


Diagnosis  of  pregnancy,   11.     See 
also  Pregnancij^  diagnosis  of. 
Diagonal  conjugate,  63 
Diameter  of  Baudelocque,   51 
Diameters  of  pelvic  inlet.  Fig.  70 

of  pelvis,  50 
Diet  in  pregnancy,  124 

in  puerperium,  125 
Differential     diagnosis    of    preg- 
nancy, 47 
Digestive  organs  of  new-born  in- 
fant, 111 
Dilatation  stage  of  labor,  75 
Diphtheritic  ulcers,  puerperal,  284 
Discus  proligerus,  17 
Disinfecting  parts  for  vaginal  ex- 
amination, 39 
Displacements  of  uterus,  170 
Ductus  Arantii,  29 
Botalli,  29 

omphalomesaraicus,  21 
Duncan's  method  of  expelling  pla- 
centa, 98 
Dwarf  pelvis,  212 
Dvstocia  from  anomalies  of  fetus, 
262 
of   umbilical   cord   and   fetal 
membranes,  266 
from  hydrocephalus,  264 
from  malformation  of  genitals, 

254 
from  twin  pregnancy,  262 

Eclampsia  gravidarum,  152 

treatment,   155 
Ectoderm,  21 
Ectopic  gestation,  191 

treatment,  197 
Eighth  month,  signs  of  pregnancv 

in,  34 
Embryo,  development  of,  21 
Endometritis,  Fig.  90 
abortion  from,  144 
decidualis  cystica.  145 
puerperal,  285 
Entoderm,  21 

Epilepsy  and  pregnancy,  164 
Epithelioma  of  chorion,  146 
Erosions  of  uterine  wall   in  labor, 
251 


INDEX. 


309 


Erysipelas  and  prejjnancy.  156 
Examination,  internal,  in  diagno- 
sis of  pregnancy,  38 

of  pelvis,  48 
Expulsion,  muscles  of,  91 

of  placenta,  97 

stage  of  labor.  85 
External  oblique  diameter.  51 

OS,  25 

False  pelvis,  5-4 
Feeding,  artificial,  118 

of  new-born  infant,  108 
Fertilization,  19 

Fetal   membranes,    anomalies    of, 
dystocia  from,  266 
development,  21 
pelvis.  228 
Fetus,  anomalies  of.  dvstocia  from. 
'262 
malformations  of.  dvstocia  from. 

264 
nutrition  and  oxygenation  of.  28 
papyraceus,  137,  263 
Fibrin,  subamniotic,  149  ;  PI.  41 
Fibroma  of  uterus,  dvstocia  from. 

260 
Fibromyoma,  Fig.  106 
and  pregnancy,  177 
Fifth  month,  signs  of  prescnancv 

in,  32 
First  month,  signs  of  pre^nancv 
in,  30 
stage  of  labor,  75 
Fixation,  point?  of.  77,  79,  80 
Flat     non-racbitic     pelvis.     215 ; 
Fig.  118 
pelvis,  cephalic  presentation  in. 

Fig.  130 

rachitic  pelvis,  217  ;  Fig.  119 

Flexion  of  uterus, dystocia  from, 256 

Fourth   month,   gravid  uterus  in, 

Fig.  19 

signs  of  pregnancy  in.  32 

Fulminating  puerperal  peritonitis, 

291 
Funic  soutRe.  37 
Funnel-shaped  pelvis.  225  :   Figs. 

51,  134 
Fiirther's  Kinderzwieback.  119 


Galactorrhea.  301 
Gangrenous  peritonitis,  291 
Gartner's  feltmilch.  119 
Generally  contracted  pelvis.  212 
Genital  secretions,  care  of.  102 
Genitalia,  lacerations  of.  in  labor. 

243 
Genitals,    malformations    <»f.   dys- 
tocia from.  254 
Gestation,  ectopic,  191 

treatment,  197 
Gravid    uterus    in    fourth   month. 
Fig.  19 
in  second  month.  Fig.  18 
in  sixth  month.  Fig.  20 
in  third  month.  Fig.  17 
\  Gunshot  wounds  and  pregnancv, 
I  166 

Haptogexic  membrane.  107 
Head,  distortions  of.  during  labor. 

89 
Hegar-s  sign.  31.  43 
Hemophilia  and  pregnancy,  163 
Hernia  labialis  uteri  gravidi  bicor- 
nis,  172 
of  gravid  uterus.  177 
:  Heubner-Soxhlet  method  for  arti- 
ficial feedincr.  120 
Hydatid  mole.  140^;  Fig.  89 
Hydrocephalus,  PI.  61,  a 
brow  presentation,  PI.  61 
;      dvstocia  from.  264 
I  Hydrorrhachis,  242 
'  Hydrorrho?a  uteri  gravidi.  144 
Hygiene  of  pregnancy,  123 
Hymen,  atresic,  dystocia  from,  258 
Hyperemesis,  161 
'  gravidarum,  231 
I  Hysteria  and  pregnancy.  164 
;  Hysterocele,  177 

:  Icterus  gravidarum.  163 

'  Impetigo    herpetiformis    gravida- 
rum, 157 

i  Impres^nation,  20 

!  Infant,  bodily  temperature  of.  114 
circulation  in.  111 
digestive  organs  of.  111 
feeding  of.  108 


310 


INDEX. 


Infant,  histological  changes  in,  109 

new-born,  care  of,  122 

nutrition  of,  108 

physiology,  108 

weight  of,  112,  113 
Infantile  pelvis,  225  ;  Fig.  134 
Infectious  diseases  and  pregnancy, 

156 
Inflammation  of  placenta,  149 
Influenza  and  pregnancy,  156 

influence  of,  on  labor,  275 
Infundibulopelvic  band,  15 
Injuries  to   child   from  deformed 

pelvis,  207 
Inspection   in   diagnosis  of  preg- 
nancy, 36 
Instrumental  labor,  278 
Instruraentarium,  281 
Intercristal  diameter,  50 
Interspinal  diameter,  50 
Intertrochanteric  distance,  51 
Intoxications  and  labor,  278 

pregnancy  and,  160 
Intra-abdominal  pressure,  68 
Intra-uterine  pressure,  68 
Inversion  of  uterus,  274 
Involution  of  uterus,  98 
Ischuria  in  labor,  277 

paradoxical,  171 

JusTOMAjOR  pelves,  243 
Juvenile  pelvis,  212 

Kidney  disease  and   pregnancy, 
164 

of  pregnancy,  164 
Kyphoscoliotic  pelvis,  229 
Kyphotic  pelvis.  Fig.  136 

Labok  and  diseases  of  other  or- 
gans, 274 
deformities  of  pelvis  and,  204 
dilatation  stage,  75 
erosions  of  uterine  wall  in,  251 
examination  in,  278 
expulsion  stage,  85 
first  stage,  75 
instrumental,  278 
instruments  for,  280 
laceration  of  cervix  in,  252 


Labor,  missed,  73 

normal,  62 

onset  of,  72 

pathology,  243 

preparations  for,  278 

rupture  of  uterus  in,  243 

second  stage  of,  85 

uterine  muscles  during,  62 
Labor-pains,  67 

abnormally  vigorous,  271 

anomalies  in,  268,  270 

convulsive,  271 

diminution  in  force  of,  271 

increase  of  force  of,  270 
Lacerations  of  cervix,  252 

of  genitalia  durinp-  labor,  243 
Lactation,  care  of  mother  in,  132 
Lactiferous  sinus,  107 
Ligamentum  cardinale,  78 
Liquor  amnii,  30 

folliculi,  17 
Lithopedia,  138 
Lochia,  97,  104 

alba,  104  ;  Fig.  84 

and  milk-secretion,  105 

rubra,  104 ;  Fig.  82 

serosa,  104 ;  Ffg.  83 
Lower  uterine  segment,  77,  81 
Lumbosacrokyphotic  pelvis,  228 
Lung  diseases  and  pregnancy,  159 
Lvmphatics   of  female  genitalia. 
Fig.  78 

MALroRMATiONS    of    fetus,    dys- 
tocia from,  264 
of  genitals,  dystocia  from,  254 
of  uterus,  168 
Malignant  deciduoma,  146 
Mammary  gland,  diseases  of,  dur- 
ing puerperium,  299 
hypersecretion  of,  301 
inflammation  of,  299 
of  blonde.  Fig.  80 
secreting  cells  of.  Fig.  79 
Masculine  pelvis,  212 
Mastitis,  299 

Maturity  of  child,  signs  of,  35 
Mayer's  ring-pessary,  172,  174 
Medullary  canal,  21 
folds,  21 


INDEX. 


311 


Meningocele,  dystocia  from,  265 
Menstruation,  17 

after  childbirth,  133 
Mesoderm,  21 
Metabolism,  disturbances  of,  and 

pregnancy,  160 
Metritis,  puerperal,  286 
Metrolymphangitis,  septic,  289 

treatment,  292 
Metrophlebothrombosis,  294 
Milk,  Fig.  86 

composition  of,  107 
Milk-secretion,  106,  132 

lochia  and,  105 
Missed  labor.  78 
Mole,  hydatid,  145 ;  Fig.  89 
Monsters,  dystocia  with,  265 
Morsus  diaboli,  20 
Mucous  membrane  of  uterus,    re- 
generation of,  105 
Miiller's  ring,   76 
Multiple  pregnancy,  262 
Mummified  fetus,  Fig.  88 
Muscles  engaged  in  expulsion,    91 
Myelitis  and  labor,  278 
Myoma  and  pregnancy,  178 

and  puerperiura,  297 

effects  of  pregnancy  on,  180 

uterine.  Fig.  108 
treatment,  184 
Myomectomv  and  pregnancv,  183, 

185 
Myxoma  chorii  multiplex,  145 

Nagele's  obliquity,  85.  216 

pelvis,  233 
iSTecrotic  decidua,  Fig.  81 

of  a  hematoma  mole,  Fig.  88 
I^fepbritis  and  pregnancy,  164 

influence  of,  on  labor,  275 
Nephrorrhapliy       during      preg- 
nancy, 167 
Nerve-supply  of  female  genitalia, 

74 
Nervous  diseases  and  pregnancv, 

160 
Nestle 's  food,  119 
Neuralgia  and  labor,  277 
Neuritis  and  labor,  278 
and  pregnancy,  164 


Neuroses,   influence  of,  on   labor. 
275 

New-born  infant,  treatment,  96 
Ninth  month,  signs  of  pregnancv 

in,  34 
Normal  labor,  62 
Nuck,  canal  of,  79 
Nutrition  of  fetus,  28 

Obliquely     contracted     pelves, 

230;  Figs.  139-142 
Obliquity,  Nagele's,  85,  216 

Solayre's,  85 
Omphalocele,  dystocia  from,  265 
Operations      during      pregnancv, 

165 
Ossification  in   normal   epiphysis. 
Fig.  124 
in  rachitic  epiphysis.  Fig.  125 
Osteomalacic         bone,         section 
through.  Fig.  126 
collapsed  pelvis,  223 
pelvis,  Fig.  123 
Ostium  abdominale,  20 
Ovarian  arteries.  26 

cysts  and  puerperium,  297 
pregnancy,  197  ;  Fig.  115 
tumors,  pregnancy  and,  186 
dystocia  from,  261 
treatment,  188 
Ovary,  15;  PI.  1,  Fig.  1 

longitudinal   section    of,    PI,    1, 
Fig.  3 
Oviduct,  cross-section  of.  16 
Ovulation,  17 
Ovum,  development,  15 
in  second  month.  Fig.  12 
in  third  month.  Fig.  13 
Oxygenation  of  fetus,  28 

Palpation  in  diagnosis  of  preg- 
nancy, 37 

Paracolpitis,  286 

Paradoxical  ischuria,  171 

Paragomphosis,  214 

Parametritis,  101 
puerperal.  286 

Parturient  canal,  anatomical  char- 
acters of,  75 

Pathology  of  labor,  243 


312 


INDEX. 


Pathology  of  pregnancy,  134 

of  puerperium,  283 
Pelveoperitonitis,  289 

treatment,  292 
Pelves,  assimilation,  241 

collapsed,  222 

deformed,  209  ;  Pis.  25,  56,  57 
classification  of,  212 

justomajor,  243 

obliquely  contracted,  230 

rubber,  224 

transversely  contracted,  236 
Pelvic  cellulitis,  287 

expansion,  plane  of,  85;  Fig.  72 

inlet,  diameters  of.  Fig.  70 
Pelvimetry,  50,  205 
Pelvis,  anatomy  of,  49 

anomalies  of  shape  of,  and  preg- 
nancy, 167 

anteroposteriorly  contracted,  215 

bone-tumors  of,  242 

changes  in  development,  58 

circumference  of,  51 

contracted,  Fis:.  50 

decubital,  228 T  Fig.  51 

deformities  of,  influence  of,  on 
labor,  204 

diameters  of,  50 

dwarf,  212 

examination  of,  48,  49 

external  measurements  of,  50 

false,  54 

fetal,  58,  228 ;  Figs.  52,  53 

flat  non-rachitic,  215,  217  ;  Fig. 
118 
rachitic,  217  ;  Fig.  119 

funnel-shaped,    225;    Figs.    50, 
134 

generallv  contracted,  212  ;  Fig. 
120^^ 

halisteretica,  223 

inclination  of,  56 
variations  in,  60 

infantile,  225;  Fig.  134 

juvenile,  212 

kyphoscoliotic,  229 

kyphotic,  Fig.  136 

lumbosacrolcyphotic,  228 

masculine,  212 

Nagele's,  233 


Pelvis  nana,  212 
normal,  Fig.  49 
obliquely  contracted,  230 ;  Figs. 

139-142 
osteomalacic,  Fig.  123 

collapsed,  223 
pseudo-osteomalacic,   220  ;   Fig. 

122 
Pvobert's,  236  ;  Fig.  144 
rubber,  224 
shape  of,  56 
sitz,  237 
spiny.  Fig.   148 
split.  Fig"  147 
spondylolisthetic,      239 ;       Fig. 

143 
synostotic,  233 
true,  54 
Pendulous  abdomen.  Figs.  99,  128. 

129 
Perforation  peritonitis,  167 
Perimetritis,  101 
Perineum,  muscles  of,  74 
Peritonitis,  fulminating  puerperal, 
291 
gangrenous,  291 
perforation,  167 
puerperal,  289 
Pfliiger's  cell-cords,  16 
Phlegmasia  alba  dolens,  294 
Phthisis,    influence    of,    on   preg- 
nancy, 159 
Physiologv   of    new-born    infant, 
108 
of  pregnancy,  11 
of  puerperium,  96 
Placenta  circumvallata,  28 
expulsion  of,  97 
inflammation  of,  149 
prjevia,  199 ;  Fig.  23 
course,  202 
diagnosis,  202 
marginal.  Fig.  27 
treatment,  203 
premature  separation  of,  267 
retention  of,  267 
scroti na,  28 

succenturiata,  199;  Fig.  13 
syphilis  of,  149 
velamentous  insertion  of,  201 


INDEX. 


313 


Placental  infarct,  Figs.  95,  101 

in  eclampsia,  Fig.  96 
Plane  of  greatest  pelvic  expansion, 
54 

of  inlet,  54 

of  least  pelvic  expansion,  55 
of  outlet,  55 

of  pelvic  expansion,  85  ;  Fig.  72 
Plicae  palmate^,  25 
Pneumonia  and  pregnancy,   159 
Polygalactia,  301 
Polyhydramnion,  147 
Portio   vaginalis,    examination  of, 

41 
Position.  Walcher,  60 
Pregnancv,  abdominal,  195  ;  Fig. 
116 
alterations  of  non-sexual  organs 

in,  46 
anatomical  features  of,  30 
and  diseases   of    other    organs, 

156 
anomalies  of  genitals  and,  168 
deformities  of  pelvis  and,  204 
diagnosis,  11 

auscultation  in,  37 
examination,  35 
in  eicchth  month,  34 
in  fifth  month.  32 
in  first  month,  30 
in  fourth  month.  32 
in  ninth  month,  34 
in  second  month,  31 
in  seventh  month,  33 
in  sixth  month,  33 
in  tenth  month,  34 
in  third  month,  31 
inspection  in,  36 
internal  examination  in,  38 
diagnostic  signs  of,  45 
differential  diagnosis  of,  47 
ectopic,  191 

treatment,  197 
hygiene  of,  123 
management  of,  123 
ovarian,  197  ;  Fig.  115 
pathology,  134 
physiology,  11 

reasons    for  determining   exist- 
ence of,  11 


Pregnancy,  signs  of,  12 
termination  of,  44 
traumatism  during,  165 
tubal,  191  ;  Fig.  112 
tubo-ovarian,  197 
tumors  and,  177 
twin,  262 

uterine  displacements  and,  170 
Prescriptions    used     in     obstetric 

practice,  302 
Principal  plane  of  Yeit,  89  ;  Fig. 

71 
Procho\vnik"6  diet,  116 
Prolapse  of  gravid  uterus,  173 

of  umbilical  cord,  266 
Pseudo-osteomalacic    pelvis,  220  ; 

Fig.  122 
Ptyalism  and  pregnancy,  162 
Puerpera,  treatment  of,  130 
Puerperal  colpitis,  285 

diphtheritic   endometritis,    Fig. 
159 
ulcers  of  vulva  and  vagina, 
284 
endometritis,  285 
fever.  101,  131,  283 
metritis,  286 
parametritis,  286 
peritonitis,  289 

fulminating,  291 
processes  and  other  diseases,  296 
salpingitis,  289 
uterus,  Fig.  28 
section  of,  Fig.  87 
Puerperium,  96 
management,  125 
pathology,  283 
physiology,  96 
symptomatology.  125 
tumors  and,  297 
Pulse  in  puerperium.  105 
I  Purpura  hemorrhagica  and  preg- 
nancy, 163 
Pyelonephritis     and     pregnancy, 

164 
Pyofibrinous  peritonitis,  291 

Eegeneration  of  uterine  mucous 

membrane,  105 
Kenal  diseases  and  pregnancy,  164 


314 


INDEX. 


Restitution-force  of  uterus,  68 
Retention  of  placenta,  267 
Retractores  uteri,  79 
Retroflexion  of  gravid  uterus,  170; 

Fig.  102 
Retroversion  of  gravid  uterus,  170 
Robert's  pelvis,  236 

transversely    contracted    pelvis, 
Fig.  144 
Rotation,  first,  85 
second,  85 
third,  95 
varieties  of,  96 
Rubber  pelvis,  224 
Ruge's  muscle-rhomboids,  64 
Rupture    of   cervix    and   vaginal 
fornix,  92 
of  tubal  sac,  167 
of  uterus,  167 

complete, '  Fig.  1 52 
in  labor,  243' 
transverse.  Fig.  110 
Ruptured  tubal  gestation-sac,  Fig. 
113 

SACCULATioisr   of  uterus,  dystocia 

from,  256 
Sacrum,    curve    of,     in     normal, 

rachitic,    and    osteomalacic 

pelves.  Fig.  131 
Salpingitis,  puerperal,  289 

treatment,  292 
Sapremia,  291 

treatment,  293 
Sarcoma  deciduocellulare,  146 
Scarlatina  and  pregnancy,  157 
Schultze's   method   of   separating 

placenta,  97 
Scorbutus  and  pregnancy,  163 
Second  month,  gravid  uterus  in. 

Fig.  18 
signs  of  pregnancy  in,  31 
stage  of  labor,  85 
Septic  metrolymphangitis,  289 
Septicemia,  treatment,  293 
Septicopyemia,  291 
Seventh    month,    signs    of    preg- 
nancy in,  33 
Sight,    appearance   of,    in    infant, 

160 


Signs  of  pregnancy,  12 

relative  value  of,  13 
Sitz  pelvis,  237 
Sixth  month,  fetus  of,  34 

gravid  uterus  in,  Fig.  20 
signs  of  pregnancy  in,  33 
Skull,  configuration  of,  85 
fetal,  size  of,  86 
of  child  at  term,  Figs.  73,  74 
of  infant  at  term,  dimensions  of, 
87 
Solayre's  obliquity,  85 
Soldner's  condensed  cream,  122 
Souffle,  funic,  37 
Soxhlet's  method  of  feeding,  118 
Spasms,  influence  of,  on  labor,  276 
Spina  bifida,  dystocia  from,  265 
Split  pelvis.  Fig.  147 
Spondylolisthetic      pelvis,      239 ; 

Fig.  143 
Stratum  vasculosum,  64 
Subamniotic  fibrin,  149  ;  PL  41 
Subchorionic  hemorrhage,  PI.  41 
Syncytium,  27 
Synostotic  pelvis,  233 
Syphilis  of  placenta,  149    . 
Syphilitic  umbilical  cord,  section 
of,  Fig.  94 

Temperature   in   new-born    in- 
fant, 114 
Tenth  month,  signs  of  pregnancy 

in,  34 
Tetanus  and  pregnancy,  156 

uteri,  270 
Tetany  and  pregnancy,  164 
Third^  month,    gravid   uterus  in, 
Fig.  17 
signs  of  pregnancy  in,  31 
Torsion  of  umbilical  cord,  266 
Transverse  diameter,  55 
of  outlet,  54 
of  pelvic  outlet,  51 
Transversely     contracted     pelves, 

236 
Traumatism    during     pregnancy, 

165 
True  pelvis,  64 
Tubal  menstruation,  19 
pregnane}^,  191  ;  Fig.  112 


INDEX. 


315 


Tubal  sac,  rupture  of,  167 
Tuberculosis  and  labor,  274 
Tubo-ovarian  pregnancy,  197 
Tumors,  177 

and  the  puerperium,  297 

of  pelvic  bones,  242 

of  vagina,  dystocia  from,  259 

ovarian,  dystocia  from,  201 
Tunica  albuginea  ovarii,  16 
Tussis  uterina,  163 
Twin  pregnancy,  262 
Typhoid  fever  and  pregnancy,  156 

Umbilical  arteries,  29 

cord,     anomalies     of,    dystocia 
from,  266 

prolapse  of,  266 

torsion  of,  266 

twisting  of,  rig.  100 
Uterine  bruit,  32,  37 

contractions,  causes  of,  73 
fibromata,  dystocia  from,  260 
isthmus,  20 
muscle,  atony  of,  272 

during  pregnancy  and  labor, 
62 
segment,  lower,  77,  81 
wall,  erosions  of,  in  labor,  251 
Uterus,  anatomv  of,  25 
arteries  of,  26  ;  Fig.  31 
bicornis,  168 

septus,  Fig.  97 
bilocularis,  168 
cancer  of,  189 
didelphys,  168 
displacements  of,  170 
flexion  of,  dystocia  from,  256 
gravid,  anteflexion  of,  174 

hernia  of,  177 

prolapse  of,  173 

retroflexion  of,  Fig.  102 

retroversion  of,  170 
introrsum  arcuatus,  Fig.  98 
inversion  of,  274 


Uterus,  involution  of,  98 
malformations  of,  168 
of  fetus,  section  of,  Fig.  14 
pregnant,  venous    plexuses   of, 

Fig.  77  _ 
puerperal,  Fig.  28 
rupture  of,  167 

complete,  Fig.  152 

in  labor,  243 

transverse.  Fig.  110 
sacculation   of,    dvstocia    from, 

257 
septus,  168 

dystocia  from,  255 
unicornis,  168 

dystocia  from,  254 

pregnancy  in,  Fig.  Ill 

VACCTNATioisr  and  pregnancy,  156 
Vagina,  bacteria  of,  103 
puerperal  diphtheritic  ulcers  of, 

284 
septa,  dystocia  from,  258 
Vaginal  examination  in  diagnosis 
of  pregnancy,  38 
tumors,  dystocia  from,  259 
Variola  and  pregnancy,  156 
Yeit,  principal  plane  of,  84,  89 
Velamentous  insertion  of  placenta. 

201 
Venous     plexuses     of     pregnant 

uterus,  Fig.  78 
Vomiting  of  pregnancy,  31 
Yulva  of  primigravida,  Fig.  37 
puerperal  diphtheritic  ulcers  of, 
284 

Walchee  position,  60 

Weight  of  infant,    variations    in, 

113 
Wetnurses,  qualifications  of,  121 

Zona  granulosa,  17 
pellucida,  17,  21 


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AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

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AN  AMERICAN   TEXT=BOOK  OF  THE   DISEASES  OF  CHIL= 
DREN.     Second  Edition,  Revised. 

Edited  by  Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hos- 
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AN  AMERICAN  TEXT=BOOK  OF   DISEASES  OF  THE   EYE, 
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Edited  by  G.  E.  DE  ScHWEiNlTZ,  M.  D.,  Professor  of  Ophthalmology, 
Jefferson  ^ledical  College,  Philadelphia  ;  and  B.  Alexander  Randall_ 
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Imperial  octavo,  1251  pages ;  766  illustrations,  59  of  them  in  colors. 
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AN    AMERICAN    TEXT=BOOK    OF    QENIT0=UR1NARY    AND 

SKIN  DISEASES. 

Edited  by  L.  BOLTON  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery, 
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Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical 
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AN    AMERICAN    TEXT=BOOK   OF    LEGAL    MEDICINE    AND 
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Edited  by  FREDERICK  PETERSON,  M.  D.,  Chief  of  Clinic,  Nervous  Depart- 
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Haines,  M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  To.xicology,  Rush 
Medical  College,  Chicago.     In  Preparatioyi. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

Edited  by  RICHARD  C.  NoRRis,  M.  D. ;  Art  Editor,  Robert  L.  Dickinson, 
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Shortly. 

AN  AMERICAN  TEXT=BOOK  OF  PHYSIOLOGY.     Second  Edi= 
tion.  Revised,  in  Two  Volumes. 

Edited  by  WILLIAM  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physiology, 
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THE  NEW   STANDARD  THE   NEW   STANDARD 

THE  AMERICAN  ILLUSTRATED  MEDICAL  DICTIONARY. 

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THE   AMERICAN    POCKET    MEDICAL    DICTIONARY.    Third 

Edition,  Revised. 

Edited  by  W.  A.  Newman  Dorland.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  American  Acad- 
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THE  AMERICAN  YEAR=BOOK  OF  MEDICINE  AND  SURGERY. 

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ABBOTT  ON  TRANSMISSIBLE  DISEASES. 

The  Hygiene  of  Transmissible  Diseases:  their  Causation,  Modes  of  Dissem- 
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with  numerous  illustrations.     Cloth,.  $2.00  net. 


MEDICAL   PL'S  Lie  A  TIONS 


ANDERS'  PRACTICE  OF  MEDICINE.    Fourth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  JAMES  M.  ANDERS,  M.  D., 
Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical  Med- 
icine, Medico-Chirurgical  College,  Philadelphia.  Handsome  octavo  volume 
of  1292  pages,  fully  illustrated.     Cloth,  $5.50  net;  Sheep  or  Half  Morocco, 

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BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  Edson  S.  Bastin,  AI.  A.,  late  Pro- 
fessor of  Materia  Medica  and  Botany,  Philadelphia  College  of  Pharmacy. 
Octavo,  536  pages,  with  87  plates.     Cloth,  $2.00  net. 

BECK  ON  FRACTURES. 

Fractures.  By  Carl  Beck,  M.  D.,  Surgeon  to  St.  Mark's  Hospital  and 
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BECK'S  SURGICAL   ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Surgeon  to  St, 
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BOISLINIERE'S    OBSTETRIC    ACCIDENTS,    EMERGENCIES, 

AND  OPERATIONS. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Boislin- 
lERE,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical  Col- 
lege.    381  pages,  handsomely  illustrated.     Cloth,  <;2.oo  net. 

BOHM,   DAVIDOFF,   AND   HUBER'S   HISTOLOGY. 

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HuBER,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of  Histological 
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351  beautiful  original  illustrations.     Cloth,  S3-5o  net. 

BUTLER'S      MATERIA      MEDICA,     THERAPEUTICS,     AND 
PHARMACOLOGY.    Third  Edition,  Revised. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharmacology.  By 
George  F.  Butler,  Ph.G..  M.  D.,  Professor  of  Materia  Medica  and  of 
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CERNA    ON    THE    NEWER     REMEDIES.       Second     Edition, 
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Physiologv,  Medical  Department,  University  of  Texas.  Rewritten  and 
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OF    n:    R.  SAUNDERS  &-    CO. 


CHAPIN  ON  INSANITY. 

A  C()ini)en(Iium  of  Insanity.  By  JOHN  B.  Chapin,  M.  D.,  LL.D.,  Fhy- 
sician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  Honorary  Member 
of  the  Medico-Psychological  Society  of  Great  Britain,  of  the  Society  of 
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CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman,  M.  D., 
Professor  of  Institutes  of  Medicine  and  Medical  jurisprudence,  Jefferson 
Medical  College  of  Philadelphia.  254  pages,  with  55  illustrations  and  3 
full-page  plates  in  colors.     Cloth,  ^1.50  net. 

CHURCH  AND  PETERSON'S  NERVOUS  AND  MENTAL  DIS= 

EASES.    Second  Edition. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Chnic,  Nervous  Department,  Col- 
lege of  Physicians  and  Surgeons,  New  York.  Handsome  octavo  volume  of 
843  pages,  profusely  illustrated.  Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco. 
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CLARKSON'S  HISTOLOGY. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur  Clark- 
son,  M.  B.,  C.  M.  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's 
College,  Manchester  ;  late  Demonstrator  of  Physiology  in  Yorkshire  College, 
Leeds.  Large  octavo,  554  pages  ;  22  engravings  and  174  beautifully  colored 
original  illustrations.     Cloth,  ^4.00  net. 

CORWIN'S  PHYSICAL  DIAGNOSIS.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  ARTHUR  M.  CORWIN, 
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Chicago.     219  pages,  illustrated.     Cloth,  $1.25  net. 

CROOKSHANK'S   BACTERIOLOGY.     Fourth  Edition,  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  \1.  B.,  Pro- 
fessor of  Comparative  Pathology  and  Bacteriology,  King's  College,  London. 
Octavo,  700  pages,  273  engravings  and  22  original  colored  plates.  Cloth, 
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DACOSTA'S  SURGERY.    Third  Edition,  Revised. 

Modern  Surgery,  General  and  Operative.  By  JOHN  CHALMERS  DaCosta, 
M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery,  Jefferson 
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Enlarged  by  over  200  Pages,  with  more  than  100  New  IIIus= 

trations. 


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DAVIS'S  OBSTETRIC  NURSING. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M.,  M.  D., 
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i2mo  volume  of  400  pages,  fully  illustrated.     Crushed  buckram,  ^1.75  net. 

DESCHWEINITZ  ON  DISEASES  OF  THE  EYE.    Third  Edition, 
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Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G.  E. 
DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical 
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DORLAND'S  DICTIONARIES. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania  ;  Associate  in  Gyne- 
cology, Philadelphia  Polychnic.  760  pages;  163  illustrations  in  the  text  and 
6  full-page  plates.     Cloth,  ^2.50  net. 

EICHHORST'S  PRACTICE  OF  MEDICINE. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Herman  Eichhorst, 
Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the  Medi- 
cal Clinic,  University  of  Zurich.  Translated  and  edited  by  AUGUSTUS  A. 
Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic, 
In  Press.     Ready  Soon. 

FRIEDRICH  AND  CURTIS  ON  THE  NOSE,  THROAT,  AND 
EAR. 

Rhinology,  Laryngology,  and  Otology,  and  their  Significance  in  General 
Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H.  HOLBROOK 
Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose  and  Throat  Hos- 
pital.    Octavo,  348  pages.     Cloth,  $2.50  net. 

FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M,  D.  v.,  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield  Scien- 
tific School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

GARRIGUES'    DISEASES    OF    WOMEN.     Third  Edition,   Re- 
vised. 

Diseases  of  Women.  By  Henry  J.  Garrigues,  A.  M.,  M.  D.,  Gynecolo- 
gist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  York  City. 
Octavo,  756  pages,  with  367  engravings  and  colored  plates.  Cloth,  ^4.50 
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OF  IV.  B.   SAUNDERS  <^  CO. 


GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  GE(jRGli  M.  GoULD,  M.  D., 
and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of  rare  and  ex- 
traordinary cases  and  of  the  most  striking  instances  of  abnormality  in  all 
branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive  research  of 
medical  literature  from  its  origin  to  the  present  day,  abstracted,  classified, 
annotated,  and  indexed.  Handsome  octavo  volume  of  968  pages ;  295  en- 
gravings and  12  full-page  plates.  Popular  Edition.  Cloth,  $3.00  net ;  Sheep 
or  Half  Morocco,  $4.00  net. 

QRAFSTROM'S  MECHANO=THERAPY. 

A  Text- Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
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GRIFFITH  ON  THE  BABY.     Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  GRIFFITH,  M.  D.,  Clinical  Pro- 
fessor of  Diseases  of  Children,  University  of  Pennsylvania  ;  Physician  to  the 
Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages,  67  illustrations 
and  5  plates.     Cloth,  ^1.50  net. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  GRIFFITH,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania.  25 
charts  in  each  pad.     Per  pad,  50  cts.  net. 

HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  Health.  By  Mrs.  Ernest  Hart,  formerly  Student 
of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School  of  Medicine 
for  Women  ;  with  an  Introduction  by  SiR  Henry  Thompson,  F.  R.  C.  S., 
M.  D.,  London.     220  pages.     Cloth,  ^1.50  net. 

HAYNES'   ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of  Prac- 
tical Anatomy  in  Cornell  University  Medical  College.  680  pages ;  42  dia- 
grams and  134  full-page  half-tone  illustrations  from  original  photographs  of 
the  author's  dissections.     Cloth,  $2.50  net. 

HEISLER'S  EMBRYOLOGY. 

A  Text-Book  of  Embryology.  By  JOHN  C.  Heisler,  M.  D.,  Professor  of 
Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume  of  405 
pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 

HIRST'S  OBSTETRICS.     Second  Edition. 

A  Text-Book  of  Obstetrics.  By  BARTON  CoOKE  HiRST,  M.  D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume  of  848 
pages ;  618  illustrations  and  7  colored  plates.  Cloth,  ^5.00  net  ;  Sheep  or 
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MEDICAL   PUBLICATIONS 


HYDE  &  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.    2d  Edition,  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D.,  Pro- 
fessor of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery,  M.  D., 
Associate  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Diseases  in  Rush 
Medical  College,  Chicago,  111.  Octavo,  594  pages,  profusely  illustrated. 
Cloth,  ^4.00  net. 

THE  INTERNATIONAL  TEXT=BOOK  OF  SURGERY.     In  Two 
Volumes. 

By  American  and  British  Authors.  Edited  by  J.  COLLINS  Warren,  M.  D., 
LL.  D.,  F.  R.C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School, 
Boston  ;  and  A,  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer  on  Practical 
Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School,  London,  Eng.  Vol.  I.  Genej-al  Surgery. — Handsome  octavo,  947 
pages,  with  458  beautiful  illustrations  and  9  lithographic  plates.  Vol.  H. 
Special  or  Regional  Surgery. — Handsome  octavo,  1072  pages,  with  471 
beautiful  illustrations  and  8  lithographic  plates.  Sold  by  Subscripiion . 
Prices  per  volume  :  Cloth,  $5.00  net :  Sheep  or  Half  Morocco,  ^6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The 
cHnician  and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a 
satisfaction  to  the  editors  as  it  is  a  gratification  to  the  conscientious  reader." — Annals  of 
Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has 
very  many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different 
authors  is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor 
of  each  writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the 
technique  of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up 
to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional 
parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which 
the  reader  may  not  learn  something  new." — Medical  Record,  New  York. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  EDWARD  JACKSON,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polychnic  and  Col- 
lege for  Graduates  in  Medicine.  i2mo,  volume  of  535  pages,  with  178  illus- 
trations, mostly  from  drawings  by  the  author.     Cloth,  ^2.50  net. 

KEATING'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  JOHN  M.  KEATING,  M.  D.,  Fellow 
of  the  College  of  Physicians  of  Philadelphia  ;  Ex-President  of  the  Association 
of  Life  Insurance  Medical  Directors.  Royal  octavo,  211  pages.  With 
numerous  illustrations.     Cloth,  ^2.00  net. 

KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm.  W. 
Keen,  M.  D.,  LL.D.,  F,  R.  C.  S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.     Cloth,  ^3.00  net. 

KEEN'S  OPERATION  BLANK.    Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required  in  Various 
Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.), 
Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.     Price  per  pad,  of  50  blanks,  50  cts.  net. 


OF    IV.   B.  SAUXDERS  &-    CO. 


KYLE  ON  THE  NOSE  AND  THROAT.     Second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Phila- 
delphia. Octavo^  646  pages  ;  over  150  illustrations  and  6  lithographic  plates. 
Cloth,  ^4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8x135^ 
inches.  A  conveniently  arranged  Chart  for  recording* Temperature,  with 
columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Re- 
marks, etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment  of 
Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

LEVY,  KLEMPERER,  AND  ESHNER'S  CLINICAL  BACTERI= 
OLOQY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Erxst  Levy,  Professor 
in  the  University  of  Strasburg,  and  Dr.  Felix  Klemperer,  Privatdocent 
in  the  University  of  Strasburg.  Translated  and  edited  by  AUGUSTUS  A. 
ESHNER,  M.  D.',  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic. 
Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

LOCKWOOD'S  PRACTICE  OF  MEDICINE. 

.\  Manual  of  the  Practice  of  Medicine.  By  GEORGE  RoE  LOCKWOOD, 
NL  D.,  Professor  of  Practice  in  the  Women's'  Medical  College  of  the  New 
York  Infirmary,  etc.  935  pages,  with  75  illustrations  in  the  text,  and  22 
full-page  plates.     Cloth,  S2.50  net. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J.  W.  LONG,  M.'D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

MACDONALD'S   SURGICAL   DIAGNOSIS   AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W,  ]\LacDOXALD,  :\L  D.  Edin., 
F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surger}'-  and  Clinical  Surger}^ 
Hamline  University.  Handsome  octavo,  800  pages,  fully  illustrated.  Cloth, 
S5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Patholog\^  Bacteriolog}',  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  FRANK  B. 
Mallory,  a.  ^L,  M.  D.,  Assistant  Professor  of  Patholog^^  Harvard  Uni- 
versity Medical  School,  Boston;  and  James  H.  Wright,  A.  iSL,  M.  D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.  Oc- 
tavo, 396  pages,  handsomely   illustrated.     Cloth,  $2.50  net. 

McFARLAND'S    PATHOGENIC    BACTERIA.      Third    Edition, 
increased  in  size  by  over   100  Pages. 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.D.,  Professor  of  Patholog}'  and  Bacteriology,  ^ledico-Chirurgical  Col- 
lege of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely  illustrated. 
Cloth,  $3.25  net. 


lo  MEDICAL   PUBLICATIONS 


MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in  limp 
cloth,  flush  edges,  25  cts.  net. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Professor 
of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery,  University  of 
Minnesota,  College  of  Medicine  and  surgery.  Octavo  volume  of  356  pages, 
handsomely  illustrated.     Cloth,  ^2.50  net. 

MORTEN'S  NURSES'  DICTIONARY. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Containing 
Definitions  of  the  Principal  Medical  and  Nursing  Terms  and  Abbreviations  ; 
of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations, 
Foods,  Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  By 
Honnor  Morten,  author  of"  How  to  Become  a  Nurse,"  etc.  i6mo,  140 
pages.     Cloth,  ^i.oo  net. 

NANCREDE'S  ANATOMY  AND  DISSECTION.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  CHARLES 
B.  Nancrede,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with  full-page 
lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra  Cloth  (or 
Oilcloth  for  dissection-room),  S2.00  net. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  CHARLES  B.  NANCREDE,  M.  D., 
LL.D,,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.     Cloth,  ^2.50  net. 

NORRIS'S    SYLLABUS    OF    OBSTETRICS.     Third    Edition, 
Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Departmicnt  of  the  University 
of  Pennsylvania.  By  RICHARD  C.  NORRIS,  A.M.,  M.  D.,  Instructor  in 
Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth,  interleaved  for  notes, 
,         $2.00  net. 

OGDEN  ON  THE  URINE. 

Clinical  Examination  of  the  Urine  and  Urinary  Diagnosis.  A  CHnical  Guide 
for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Surgery.  By  J. 
Bergen  Ogden,  M.  D.,  Instructor  in  Chemistry,  Harvard  University  Med- 
ical School.  Handsome  octavo,  416  pages,  with  54  illustrations,  and  a  num- 
ber of  colored  plates.     Cloth,  ^3.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.    Third  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  CHARLES  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  531  pages,  handsomely  illustrated.     Cloth,  ^3.75  net. 


OF  W.  B.   SAUNDERS  &^  CO.  il 


PRYOR— PELVIC  INFLAMMATIONS. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.  By  W.  R. 
Pryor,  M.  D.,  Professor  of  Gynecology,  New  York  Polyclinic.  i2mo,  248 
pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  concerning 
the  Immed  ate  Treatment  of  Cases  of  Emergency.  By  Walter  Pye, 
F.  R.C.S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

PYLE'S  PERSONAL  HYGIENE. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic  Basis. 
Edited  by  Walter  L.  Pyle,  ^L  D.,  Assistant  Surgeon  to  the  Wills  Eye 
Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully  illustrated. 
Cloth,  $1.50  net. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital.  382  pages,  102  illustrations,  and  4  full-page  colored 
plates.     Cloth,  Si. 25  net. 

SALINGER  AND  KALTEYER'S  MODERN  MEDICINE. 

Modern  Medicine.  By  JULIUS  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College  ;  and  F.  J.  Kalteyer,  M.  D., 
Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical  College. 
Handsome  octavo,  801  pages,  illustrated.     Cloth,  34-oo  net. 

SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the  Royal 
Medico-Chirurgical  Society  ;  Professor  of  Medicine  in  Mason  College,  Bir- 
mingham, etc.  Octavo,  434  pages,  with  numerous  illustrations  and  4  colored 
plates.     Cloth,  $2.50  net. 

SAUNDERS'  MEDICAL  HAND=ATLASES.    See  pp.  16  and  17. 

SAUNDERS'   POCKET   MEDICAL   FORMULARY.     Sixth  Edi= 

tion,  Revised. 

By  William  M.  Powell,  ]SL  D.,  author  of  "  Essentials  of  Diseases  of 
Children"  ;  Member  of  Philadelphia  Pathological  Society.  Containing  1844 
formulae  from  the  best-known  authorities.  With  an  Appendix  containing 
Posological  Table,  Formulse  and  Doses  for  Hypodermic  Medication, 
Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal 
Head,  Obstetrical  Table,  Diet  List  for  Various  Diseases,  Materials  and 
Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from  Drowning, 
Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.  Handsomely  bound  in  flexible  morocco,  with  side  index,  wallet,  and 
flap.     $2.00  net. 

SAUNDERS'  QUESTION=COMPENDS.     See  pages  14  and  15. 


12  MEDICAL   PUBLICATIONS 


SCUDDER'S  FRACTURES.    Second  Edition,  Revised. 

The  Treatment  of  Fractures.  By  Chas  L.  Scudder,  M.  D.,  Assistant  in 
Clinical  and  Operative  Surgery,  Harvard  University  Medical  School.  Oc- 
tavo, 433  pages,  v^^ith  nearly  600  original  illustrations.  Polished  Buckram, 
^4.50  net;   Half  Morocco,  ^5.50  net. 

SENN'S  QENIT0=UR1NARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By  Nich- 
olas Senn,  M.  D.,  Ph.  D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.  Handsome  octavo 
volume  of  320  pages,  illustrated.     Cloth,  ^3.00  net. 

SENN'S  PRACTICAL  SURGERY. 

Practical  Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.D.,  LL.D.,  Professor 
of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical  College, 
Chicago.  Handsome  octavo  volume  of  over  1000  pages,  profusely  illus- 
trated.    In  Press. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  conformity 
with  "  An  American  Text-Book  of  Surgery."  By  NICHOLAS  Senn,  M.  D., 
Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery. 
Rush  Medical  College,  Chicago.     Cloth,  $1.50  net. 

SENN'S  TUMORS.    Second  Edition,  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  NICHOLAS  Senn,  M.  D., 
Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Surgery  and  of  Chnical  Surgery, 
Rush  Medical'  College,  Chicago.  Octavo  volume  of  718  pages,  with  478 
illustrations,  includidg  12  full-page  plates  in  colors.  Cloth,  ^5.00  net ;  Sheep 
or  Half  Morocco,  ^6.00  net. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  LouiS  STARR, 
M.D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of  Children." 
230  blanks  (pocket-book  size),  perforated  and  neatly  bound  in  flexible 
morocco.     $1.25  net. 

STENGEL'S  PATHOLOGY.  Third  Edition,  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel.  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania;  Visiting  Physician  to  the 
Pennsylvania  Hospital.  Handsome  octavo,  873  pages,  nearly  400  illustra- 
tions, many  of  them  in  colors.  Cloth,  $5.00  net;  Sheep  or  Half  Morocco, 
^6.00  net. 

STENGEL  AND  WHITE  ON  THE  BLOOD. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred  Sten- 
gel. M.  D.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania;  and 
C.Y.White,  JR-.  M.D.,  Instructor  in  Clinical  Medicine,  University  of 
Pennsylvania.     In  Press. 


OF    W.   B.  SAUXDERS   o-    CO. 


STEVENS'  MATERIA  MEDICA  AND  THERAPEUTICS.    Sec= 
ond  Edition,  Revised. 

A  Manual  of  Materia  Medica  and  Therapeutics.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania, 
Post-octavo,  445  pages.     Flexible  Leather,  ^2.00  net. 

STEVENS'  PRACTICE  OF  MEDICINE.     Fifth  Edition,  Revised. 

A  AL\nual  of  the  Practice  of  Medicine.  By  A.  A.  STEVENS,  A.  iVL,  M.  D., 
Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsylvania.  Spe- 
cially intended  for  students  preparing  for  graduation  and  hospital  examina- 
tions.    Post-octavo,  519  pages  ;  illustrated.     Flexible  Leather,  ^2.00  net. 

STEWART'S  PHYSIOLOGY.     Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and  Prac- 
titioners. By  G.  N.  Stewart,  ALA.,  M.  D.,  D.Sc,  Professor  of  Physiol- 
ogy in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  894  pages  ;  336  illustrations  and  5  colored  plates.     Cloth,  ^3.75  net. 

STONEY'S  MATERIA  MEDICA  FOR  NURSES. 

Materia  Medica  for  Nurses.  By  EMILY  A.  M.  Stonev,  late  Superintend- 
ent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston, 
Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  ^1.50  net. 

STONEY'S  NURSING.    Second  Edition,  Revised. 

Practical  Points  in  Nursing.  For  Nurses  in  Private  Practice.  By  Emily 
A.  M.  Stonev,  late  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings  and 
8  colored  and  half-tone  plates.     Cloth,  $1.75  net. 

STONEY'S  SURGICAL  TECHNIC  FOR  NURSES. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  A.  M.  Stoney, 
late  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hospital, 
South  Boston,  Mass.     i2mo  volume,  fully  illustrated.     Cloth,  $1.25  net. 

THOMAS'S  DIET  LISTS.     Second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  JEROME  B.  THOMAS,  M.D.,  In- 
structor in  Materia  Medica,  I_^ong  Island  Hospital ;  Assistant  Bacteriologist 
to  the  Hoagland  Laboratory.     Cloth,  ^1.25  net.     Send  for  sample  sheet. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITINQ. 

Dose-Book  and  Manual  of  Prescription-Writing.  By  E.  Q.  THORNTON, 
M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Philadel- 
phia.    334  pages,  illustrated.     Cloth,  $1.25  net. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 

Diseases  of  the  Stomach.  By  WILLIAM  W.  Van  Valzah,  M.  D.,  Pro- 
fessor of  General  Medicine  and  Diseases  of  the  Digestive  System  and  the 
Blood,  New  York  Polyclinic;  and  L  DOUGLAS  NiSBET,  M.  D.,  Adjunct 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System  and 
the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages,  illustrated. 
Cloth,  $3.c;o  net. 


14  MEDICAL    PUBLICATIONS. 


VECKl'S  SEXUAL  IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  VICTOR  G.  Vecki, 
M.  D.  From  the  second  German  edition,  revised  and  enlarged.  Demi- 
octavo,  291  pages.     Cloth,  ^2.00  net. 

VIERORDT'S    MEDICAL    DIAGNOSIS.      Fourth    Edition,  Re= 
vised. 

Medical  Diagnosis.  By  Dr.  OSWALD  ViERORDT,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth  en- 
larged German  edition,  with  the  author's  permission,  by  FRANCIS  H. 
Stuart,  A.  M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194  wood- 
cuts, many  of  them  in  colors.  Cloth,  4.00  net;  Sheep  or  Half-Morocco, 
^5.00  net. 

WATSON'S  HANDBOOK  FOR  NURSES. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.  D.  Edin.  American 
Edition,  under  supervision  of  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on 
Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages,  73  illus- 
trations.    Cloth,  ^1.50  net. 

WARREN'S  SURGICAL  PATHOLOGY.    Second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren,  M.  D., 
LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical  School. 
Handsome  octavo,  873  pages  ;  136  relief  and  lithographic  illustrations,  33  in 
colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis,  and  a 
series  of  articles  on  Regional  Bacteriology.  Cloth,  ^5.00  net;  Sheep  or 
Half  Morocco,  ^6.00  net. 


SAUNDERS' 
QUESTION  =  COMPENDS. 


ARRANGED  IN  QUESTION  AND  ANSWER  FORM. 


The  Most  Complete  and  Best  Illustrated  Series  of  Compends  Ever  Issued. 


NOW  THE  STANDARD  AUTHORITIES  IN  MEDICAL  LITERATURE 

WITH 

Students  and  Practitioners  in  every  City  of  the  United  States  and  Canada. 


Since  the  issue  of  the  first  volume  of  the  Saunders  Question-Compends, 

OVER  175,000  COPIES 

of   these  unrivalled   publications    have  been    sold.      This   enormous   sale   is   indisputable 
evidence  of  the  value  of  these  self-helps  to  students  and  physicians. 

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Question  =  Compend    Series 

Price,  Cloth,  $i.oo  net  per  copy,  except  when  otherwise  noted. 


"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders 
Series,  in  our  opinion,  bears  off  the  palm  at  present." — Netv  York  Medical  Record. 


1.  Essentials  of  Physiology.     A  new  work  in  preparation. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised, 

with  an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles    B.    Nancrede,    M.  D.     Sixth    edition. 

thoroughly  revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.    By  Lawrence 

Wolff,  M.  D.     Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly   Ashton,  M.  D.     Fourth   edition, 

revised  and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.    By  F.  j.  Kalteyer,  m.  d. 

In  preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- Writing. 

By  Henry  Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.     Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Ap- 

pendix on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition, 
enlarged  by  some  300  Essential  Formulse,  selected  from  eminent  authorities,  by 
Wm.  M.  Powell,  M.  D.     (Double  number,  $1.50  net.) 

10.  Essentials    of    Gynecology.     By    Edwin   B.   Cragin,   M.  D.      Fourth   edition, 

revised. 

11.  Essentials  of  Diseases  of  the  Skin.    By  Henry  w.  Stelwagon,  m.  D. 

Fourth  edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials  of  Legal  Medicine,  Toxicology,  and  Hygiene.    This  volume  is 

at  present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye,  Nose,  and  Throat.    By  Edward  Jack- 

son, M.  D.,  and  E.  B.  Gleason,  M.  D.     Second  edition,  revised. 

15.  EssentialSOf  Diseases  Of  Children.     By  William  M.  Powell,  INL  D.     Second 

edition. 

16.  Essentials  of  Examination  of  Urine.     By  Lawrence  Wolff,  M.  D.     Colored 

"  Vogel  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.  Solis-Cohen,  M.  D.,  and  A.  A.  Eshner,  M.  D. 

Second  edition,  thoroughlj'-  revised. 

18.  Essentials  of  Practice  of  Pharmacy.     By  Lucius  E.  Sayre.     Second  edition, 

revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  v.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  Of  Nervous  Diseases  and  Insanity.    By  John  c.  Shaw,  M.  D. 

Third  edition,  revised. 

22.  Essentials  of  Medical  Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edi- 

tion, revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart.  !\I.  D.,  and   Ed- 

ward S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ear.     By  E.  B.  Gleason,  M.  D.     Second  edition, 

revised  and  greatly  enlarged. 

A  NEW  VOLUME. 

25.  Essentials  of  Histology.     By  Louis  Leroy.M.D.     With  73  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 

15 


Saunders'  Medical  Hand=Atlases. 


VOLUMES  NOW  READY. 

ATLAS    AND    EPITOME    OF    INTERNAL    MEDICINE    AND 
CLINICAL   DIAGNOSIS. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  179 
colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text.  Cloth, 
^3.00  net. 

ATLAS  OF  LEGAL  MEDICINE. 

By  Dr.  E.  R.  von  Hoffman,  of  Vienna.  Edited  by  Frederick  Peter- 
son, M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of  Physicians  and 
Surgeons,  New  York.  With  120  colored  figures  on  56  plates  and  193  beau- 
tiful half-tone  illustrations.     Cloth,  $3.50  net. 

ATLAS  AND  EPITOME  OF  DISEASES  OF  THE  LARYNX. 

By  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D.,  Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the 
University  of  Pennsylvania.  With  107  colored  figures  on  44  plates,  25  text- 
illustrations,  and  103  pages  of  text.     Cloth,  ^2.50  net. 

ATLAS  AND  EPITOME  OF  OPERATIVE  SURGERY. 

By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited  by  J.  Chalmers  DaCosta, 
M.D.,  Professor  of  Principles  of  Surgery  and  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.  With  24  colored  plates,  214  text-illustra- 
tions, and  395  pages  of  text.     Cloth,  ^3.00  net. 

ATLAS  AND  EPITOME  OF  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs, 
M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  With  71  colored  plates,  16  illustrations, 
and  122  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND  EPITOME  OF  EXTERNAL  DISEASES  OF  THE 
EYE. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  DE  SCHWEINITZ,  M.  D., 
Professorof  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With 
76  colored  illustrations  on  40  plates  and  228  pages  of  text.     Cloth,  ^3.00  net. 

ATLAS  AND  EPITOME  OF  SKIN  DISEASES. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON.  M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  Col- 
lege, Philadelphia.  With  63  colored  plates,  39  half-tone  illustrations,  and 
200  pages  of  text.     Cloth,  ^3.50  net. 

ATLAS  AND   EPITOME  OF  SPECIAL  PATHOLOGICAL  HIS= 
TOLOGY. 

By  Dr.  H.  Durck,  of  Munich.  Edited  by  LUDWlG  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.  Ready,  including  Circulatory,  Respiratory,  and  Gastro-intestinal 
Tract,  120  colored  figures  on  62  plates,  158  pages  of  text.  Part  H.  Ready 
Shortly.     Price  of  Part  I.,  ^3.00  net. 

16 


Saunders'  Medical  Hand=Atlases. 


VOLUMES   JUST  ISSUED. 

ATLAS   AND   EPITOME    OF    DISEASES   CAUSED   BY   ACCI- 
DENTS. 

Bv  Dr.  Ed.  GoLKHih:\V;.Kl,  of  Berlin.  Translated  and  edited  with  addi- 
tions by  Pearce  Bailey,  M.D.,  Attending  Physician  to  the  Department 
of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals,  New  York. 
With  40  colored  plates,  143  te.xt-illustrations,  and  600  pages  of  text.  Cloth, 
34.00  net. 

ATLAS  AND  EPITOME  OF  GYNECOLOGY. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited  bv  RICHARD  C.  XORRIS,  A.  M.,  M.D.,  Gynecologist  to 
the  Methodist  Episcopal  and  the  Philadelphia  Hospitals;  Surgeon-in-Charge 
of  Preston  Retreat,  Philadelphia.  With  90  colored  plates,  65  text-illustra- 
tions, and  308  pages  of  text.     Cloth,  S3. 5°  net. 

ATLAS   AND   EPITOME  OF   THE   NERVOUS  SYSTEM  AND 
ITS  DISEASES. 

Bv  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised 
German  Edition.  Edited 'by  EDWARD  D.  FiSHER,  M.  D.,  Professor  of 
Diseases  of  the  Nervous  System,  University  and  Bellevue  Hospital  Medical 
College,  New  York.    With  83  plates  and  a  copious  text.    $3.50  net. 

ATLAS   AND   EPITOME  OF   LABOR   AND   OPERATIVE  OB- 
STETRICS. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  Frotn  the  Fifth  Revised  German 
Edition.  Edited  by  J,  CLIFTON  Edgar,  M.  D.,  Professor  of  Obstetrics  and 
Clinical  Midwifery,  Cornell  University  Medical  School.  With  126  colored 
illustrations.    $2.00  net. 

ATLAS  AND  EPITOME  OF  OBSTETRICAL  DIAGNOSIS  AND 
TREATMENT. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited  by  J.  CLIFTON  EDGAR,  M.  D,,  Professor  of  Obstetrics 
and  Clinical  Midw-ifery,  Cornell  University  Medical  School.  72  colored 
plates,  numerous  text-illustrations,  and  copious  text.     $3.00  net. 


IN   PRE:SS   for  early  PUBLICATION. 

ATLAS  AND   EPITOME  OF  OPHTHALMOSCOPY  AND  OPH» 
THALMOSCOPIC   DIAGNOSIS. 

By  Dr.  O.  Haab,  of  Zurich.  Frojn  the  Third  Revised  and  Enlarged  Ger- 
man Edition.  Edited  bv  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Oph- 
thalmology, Jefferson  Medical  College,  Philadelphia.  With  149  colored 
figures  and  82  pages  of  text. 


ADDITIONAL  VOLUMES   IN   PREPARATION. 

17 


CLASSIFIED  LIST 

OF  THE 

MEDICAL    PUBLICATIONS 

OF 

W.  B.  SAUNDERS  &  COMPANY 


ANATOMY,  EMBRYOLOGY,  HIS- 
TOLOGY. 

Bohm,  Davidoff,  and  Huber— A  Text- 
Book  of  Histology, 4 

Clarkson— A  Text-Book  of  Histology,   .  5 

Haynes— A  Manual  of  Anatomy,   ...  7 

Heisler — A  Text-Book  of  Embryology,  .  7 

Leroy — Essentials  of  Histology,     ....  15 

Nancrede — Essentials  of  Anatomy,  ...  15 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  ....  10 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ....  15 

Crookshank — Bacteriology, 5 

Frothingham — Laboratory  Guide,  ...  6 
Levy  and  Klemperer's  Clinical  Bacte- 
riology,      9 

Mallory    and     Wright— Pathological 

Technique, 9 

McFarland — Pathogenic  Bacteria,  ...  9 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart,  ....  7 

Hart — Diet  in  Sickness  and  in  Health,    .  7 

Keen — Operation  Blank, 8 

Laine — Temperature  Chart, 9 

Meigs — Feeding  in  Early  Infancy,    ...  10 

Starr — Diets  for  Infants  and  Children,  .  12 

Thomas — Diet-Lists, 13 

CHEMISTRY  AND  PHYSICS. 

Brock\A/ay  —  Essentials    of   Medical 

Physics, 15 

Wolff— Essentials  of  Medical  Chemistry,  15 

CHILDREN. 
An  American  Text-Book  of  Diseases 

of  Children i 

Griffith— Care  of  the  Baby 7 

Griffith— Infant's  Weight  Chart,  ....  7 
Meigs — Feeding  in  Early  Infancy,    ...  10 
Powell — Essentials  of  Diseases  of  Chil- 
dren,       15 

Starr — Diets  for  Infants  and  Children,    .  12 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 
nosis,      15 

Corwin — Physical  Diagnosis, 5 

Macdonald — Surgical     Diagnosis     and 

Treatment, 9 

Vierordt— Medical  Diagnosis, 14 

DICTIONARIES. 

The    American    Illustrated     Medical 

Dictionary, •    •  3 

The  American  Pocket  Medical  Dic- 
tionary,      3 

Morton— Nurses'  Dictionary, 10 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases 
of  the  Eye,  Ear,  Nose,  and  Throat,  .    .      i 

De  Schweinitz — Diseases  of  the  Eye,    .     6 

Friedrich  and  Curtis — Rhinology,  Lar- 
yngology, and  Otology, 6 

Gleasjn — Essentials  of  Diseases  of  the 
Ear, 15 

Grunwald  and  Grayson — Atlas  of  Dis- 
eases of  the  Laryn.x, 16 

Haab  and  De  Schweinitz — Atlas  of  Ex- 
ternal Diseases  of  the  Eye,  16 

Jackson — Manual  of  Diseases  of  the  Eye,     8 

Jackson  and  Gleason — Essentials  of 
Diseases  of  the  Eye,  Nose,  and  Throat,   15 

Kyle — Diseases  of  the  Nose  and  Throat,     9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 2 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 8 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,  .    .    15 

Mracek  and  Bangs — Atlas  of  Syphilis 
and  the  Venereal   Diseases, 16 

Saundby — Renal  and  Urinary  Diseases,   11 

Senn— Genito-Urinary  Tuberculosis,    .    .    12 

Vecki — Sexual  Impotence, 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,   .  2 

Cragin — Essentials  of  Gynecology,  ...  15 

Garrigues — Diseases  of  Women,  .    ...  6 

Long — Syllabus  of  Gynecology,    ....  9 

Penrose — Diseases  of  Women, 10 

Pryor — Pelvic  Inflammations, 11 

Schaeffer  and  Norris — Atlas  of  Gyne- 
cology,       17 

MATERIA      MEDICA,      PHARMA- 
COLOGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics i 

Butler— Text-Book  of  Materia  Medica, 

Therapeutics,  and  Pharmacology,  .  .  4 
Cerna — Notes  on  the  Newer  Remedies,  .  4 
Morris  — Essentials   of   Materia   Medica 

and  Therapeutics, 15 

Saunders'  Pocket  Medical  Formulary,  .  11 
Sayre — Essentials  of  Pharmacy,  ....  15 
Stevens — Manual  of  Therapeutics,  ...  13 
Stoney— Materia  Medica  for  Nurses,  .  .  13 
Thornton— Dose-Book   and    Manual   of 

Prescription- Writing,      13 

MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman— Medical  Jurispi-udence  and 
Toxicology, 5 


MEDR -A L    P UBLICA  TIONS 


19 


Golebiewski  and  Bailey— Atlas  of  Dis- 
eases Caused  by  Accidents, 17 

Hofmann  and  Peterson — Atlas  of  Legal 
Medicine, 16 

NERVOUS    AND    MENTAL    DIS- 
EASES, ETC. 

Chapin— Compendium  of  Insanity.  ...  5 
Church   and    Peterson — Nervous   and 

Mental  Diseases, 5 

Shaw — Essentials  of  Nervous   Diseases 

and  Insanity, 15 

NURSING. 
Davis — Obstetric  and  Gynecologic  Nurs- 
ing,      6 

Griffith— The  Care  of  the  Baby,  ....  7 

Hart — Diet  in  Sickness  and  in  Health,  .    .  7 

Meigs — Feeding  in  Early  Infancy,    ...  10 

Morten — Nurses'   Dictionary, 10 

Stoney — Materia  Medica  for  Nurses,  .    .  13 

Stoney — Practical  Points  in  Nursing,  .    .  13 

Stoney — Surgical  Technic  for  Nurses,    .  13 

Watson — Handbook  for  Nurses,  ....  14 


OBSTETRICS. 

An  American  Text-Rook  of  Obstetrics 
Ashton — Essentials  of  Obstetrics,  .  .  . 
Boisliniere — Obstetric  Accidents,  .  . 
Borland — Manual  of  Obstetrics,  .  .  . 
Hirst — Te.\t-Book  of  Obstetrics,  .  .  . 
Norris — Syllabus  of  Obstetrics,  .  .  .  . 
SchaefFer  and  Edgar— Atlas  of  Obstet- 
rical Diagnosis  and  Treatment,  .    .    .    . 


17 


PATHOLOGY. 

An  American  Text-Book  of  Pathology,     2 
Durck  and  Hekto  =  n — Atlas  of  Patho- 
logic Histologj-, 16 

Kalteyer — Essentials  of  Pathology,    .    .    15 
Mallory    and    Wright  — Pathological 

Technique, g 

Senn — Pathology',  and  Surgical  Treat- 
ment of  Tumors, 12 

Stengel— Text-Book  of  Pathology,  ...    12 
W^arren— Surgical  Pathology, 14 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiol- 
ogy',       2 

— Essentials  of  Physiology', 15 

Raymond— Manual  of  Physiology,     .    .    11 
Stewart— Manual  of  Physiology,   ...    13 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  of  Medicine 
and  Surgery-, 3 

Anders— Text-Book  of  the  Practice  of 
Medicine, 4 

Eichhorst — Practice  of  Medicine.  ...      6 

Lockwood — Practice  of  Medicine.  ...     9 

Morris— Essentials  of  Practice  of  Medi- 
cine,   15 

Salinger  and  Kalteyer— Modern  Medi- 
cine,   II 

Stevens— Manual  of  Practice  of  Medi- 
cine,   12 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 8 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal   Diseases,  .    .    15 

Mracek  and  Stelwagon — Atlas  of  Dis- 
eases of  the  Skin, 16 

Stelwagon— Essentials  of  Diseases  of 
the  Skin, 15 

SURGERY. 

An  American  Text-Book  of  Surgery,  2 
An  American  Year-Book  of  Medicine 

and  Surgery, 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis,  ...  4 

Da  Costa — Manual  of  Surgerj', 5 

International  Text-Book  of  Surgery,  .  8 

Keen— Operation  Blank, 8 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 8 

Macdonald — Surgical     Diagnosis    and 

I'reatment, 9 

Martin — Essentials  of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  .    .  15 

Martin — Essentials  of  Surgery, 15 

Moore — Orthopedic  Surgerj', 10 

Nancrede — Principles  of  Surgerj',  .    .    .  10 

Pye — Bandaging  and  Surgical  Dressing,  11 

Scudder — Treatment  of  Fractures,   ...  12 

Senn — Genito-Urinary  Tuberculosis,   .    .  12 

Senn— Practical  Surgerj-, 12 

Senn — Sjilabus  of  Surgery, 12 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 12 

Warren — Surgical  Pathology  and  Ther- 
apeutics,    14 

Zuckerkandl  and  Da  Costa — Atlas  of 

Operative  Surgery, 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical     E.xamination     of    the 

Urine, 10 

Saundby — Renal  and  Urinary  Diseases,  11 
Wolff — Examination  of  Urine, 15 

MISCELLANEOUS. 

Abbott — Hygiene  of  Transmissible  Dis- 
eases,          3 

Bastin — Laboratory  Exercises  in  Bot- 
any.          .    .     4 

Golebiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents,  .       .        •    •    17 
Gould  and   Pyle — Anomalies  and  Curi- 
osities of  Medicine, 7 

Grafstrom — Massage, 7 

Keating— Examination  for  Life  Insur- 
ance,      8 

Pyle — A  Manual  of  Personal  Hj-giene,  .  n 
Saunders' Medical  Hand-Atlases,  .  16,17 
Saunders'  Pocket  ^ledical  Formulary,  .  n 
Saunders'  Question-Compends,  .  .  14,  15 
Stewart  and  Lawrence — Essentials  of 

Medical   Electricity, 15 

Thornton — Dose-Book  and   Manual   of 

Prescription- Writing, 13 

Van  Valzah  and  Nisbet — Diseases  of 
the  Stomach, 13 


Nothnagel's  Encyclopedia 

OF 

Special  Pathology  and  Therapeutics. 


¥T  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal  Medicine; 
*  and  of  all  the  German  works  on  this  subject.  Nothnagel's  "  Special  Pathology  and 
Therapeutics"  is  conceded  by  scholars  to  be  without  question  the  best  System  of 
Medicine  in  existence.  So  necessary  is  this  book  in  the  study  of  Internal  Medicine 
that  it  comes  largely  to  this  country  in  the  original  German.  In  view  of  these  facts. 
Messrs.  W.  B.  Saunders  &  Company  have  arranged  with  the  publishers  to  issue  at  once 
an  authorized  edition  of  this  great  encj'clopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  the  most  practical 
part  of  this  encyclopedia,  and  selected  by  a  competent  editor  with  especial  thought  of  the 
needs  of  the  practical  physician,  will  be  published.  Thesevolumes  will  contain  the 
real  essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less  than  half  the 
cost  the  cream  of  the  original.  Later  the  special  and  more  strictlj'  scientific  volumes  will 
be  offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both  English  and 
German,  and  each  volume  will  be  edited  by  a  prominent  specialist  on  the  subject  to 
which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to  date,  and  the  American  edition 
will  be  more  than  a  mere  translation  of  the  German  ;  for,  in  addition  to  the  matter  contained 
in  the  original,  it  will  represent  the  very  latest  views  of  the  leading  American  special- 
ists in  the  various  departments  of  Internal  ]\Iedicine.  The  whole  System  will  be  under  the 
editorial  supervision  of  a  cli^ncian  of  recognized  authority,  who  will  select  the  subjects 
for  the  American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended  over  a 
number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming  year,  and  the 
remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume  will  be  revised  to  the 
date  of  its  publication  by  the  American  editor.  This  will  obviate  the  objection  that  has 
heretofore  existed  to  systems  published  in  a  number  of  volumes,  since  the  subscriber  will 
receive  the  completed  work  while  the  earlier  volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been  to  compel 
physicians  to  take  the  entire  Sj'stem.  This  seems  to  us  in  many  cases  to  be  undesirable. 
Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be  given  the  opportunity  of 
subscribing  for  the  entire  System  at  one  time;  but  any  single  volume  or  any  number  of 
volumes  may  be  obtained  by  those  who  do  not  desire  the  complete  series.  This  latter 
method,  while  not  so  profitable  to  the  publisher,  offers  to  the  purchaser  many  advan- 
tages which  will  be  appreciated  by  those  who  do  not  care  to  subscribe  for  the  entire  work 
at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question,  form  the 
greatest  System  of  Medicine  ever  produced,  and  the  publishers  feel  confident  that  it 
will  meet  with  general  favor  in  the  medical  profession. 

20 


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Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis.     By  Dr.  Chs. 

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217  illustrations  in  the  texl^aad 
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7DON. 


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